Eligibility and Verification of Benefits

Eligibility and Benefits verification is one of the most overlooked area of revenue cycle management although it is one the major reason for claim rejection and cannot be reversed because service has already been given to ineligible patient. We at Medstates ensures that patient is eligible for the service or Benefits and necessary authorization has been taken already before the service is received. This service if taken along with our scheduling service can be very rewarding for providers, once appointment is scheduled, immediate verification will take place.Here’s an overview of the steps involved in benefits verification:

Patient Eligibility Verification

Purpose: Verify whether the patient is eligible for the healthcare services being provided.

Process

• Collect patient information, including insurance details.
• Contact the insurance provider to verify the patient’s coverage.
• Confirm details such as policy status, effective date, coverage limits, and any specific requirements or restrictions.
• Obtain information on co-payments, deductibles, and co-insurance that the patient may be responsible for.

Insurance Verification

Purpose: Confirm the patient’s insurance coverage and gather relevant details for billing.

Process

• Verify the insurance policy information, including the policy number, group number, and the name of the primary insured.
• Confirm the type of plan (e.g., HMO, PPO) and any specific requirements or pre-authorization procedures.
• Identify if the patient has additional coverage, such as secondary insurance.

Pre-Authorization

Purpose: Ensure that certain medical procedures or services are approved by the insurance provider before they are performed.

Process

• Determine if pre-authorization is required for specific procedures.
• Submit the necessary information to the insurance company.
• Obtain approval or denial of the pre-authorization request.

Benefits Verification

Purpose: Understand the extent of coverage for specific healthcare services.

Process

• Check the benefits associated with the patient’s insurance plan.
• Determine coverage limits, exclusions, and any special conditions.
• Verify if the services being provided are covered and to what extent.

Documentation

Purpose: Maintain a record of the eligibility and benefits verification process.

Process

• Document all communications with the insurance provider, including dates, names, and details of the information obtained.
• Keep a record of the patient’s insurance details and coverage information for reference during the billing process.

Communication with Patients

Purpose: Keep patients informed about their financial responsibilities.

Process

• Clearly communicate any co-pays, deductibles, or co-insurance amounts the patient may need to pay.
• Educate patients on their insurance coverage and any potential out-of-pocket expenses.

By thoroughly conducting eligibility and benefits verification check, MedStates can help you minimize claim denials, reduce billing errors, and improve overall revenue cycle management. It is essential to stay up-to-date with changes in insurance plans and regulations to ensure accurate billing and reimbursement.