It is indisputable that healthcare is expensive in the country, and without external financial support, the majority of the population would be deprived of this essential human need, and the circumstances would be dire. The fate of the healthcare providers including clinics, doctors, and hospitals would also be uncertain and the entire ecosystem would be staring at an imminent collapse. Here, the health insurance companies emerge as the savior and help citizens combat the constantly increasing healthcare costs in the US.
However, the story doesn’t end here; in fact, it’s the beginning of a long process that entails several tasks and stakeholders. Only a flawless collaboration among the different factors involved would future-proof the financial aspect of the US healthcare system. One of the critical and foremost components of the revenue cycle management of the healthcare system is patient insurance eligibility verification.
Patient Insurance Verification and its Importance
Whenever an individual approaches a healthcare facility seeking treatment for any medical condition they are suffering from, one of the initial responsibilities of the care provider/ physician is to verify the eligibility of the patient for the treatment required. This is done by carrying out a thorough analysis of the insurance coverage of the patient and ensuring that the policy covers the treatment the patient needs.
What to Verify in an Insurance Document?
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This process is termed as insurance verification services. Besides the first appointment, the verification process is also executed on the date of service and subsequent follow-ups. This way, both the patient and the care provider are relieved of the financial burden of the treatment and the patient can be given the best care. If the coverage makes the patient eligible for the healthcare services, the provider can rest assured to get paid for the same by the insurance carrier. An efficient verification process takes into account the demographic data of the patient’s coverage; the services its covers; the benefits, copayments, coinsurance; and prior authorization requirements for the treatment.
Well-laid-out healthcare insurance verification services is critical for providers to ensure that they get paid for the services rendered to the patient. In other words, it helps them maximize the chances of successfully processing the claims they send out to the insurer at the end of the treatment. On the flip side, a lousy process implies delayed/denied/rejected claims, claims resubmission, and patient dissatisfaction.
Major Pain Points in a Typical Patient Eligibility Verification Process
The outcome of the healthcare insurance eligibility verification services has a significant bearing on whether the provider will get paid by the insurers. Notwithstanding its significance, it remains one of the riskiest, most tedious, and error-prone component in the healthcare revenue cycle. Here are the common obstacles to the regular patient insurance verification process.
Manual process: Healthcare insurance verification comprises several large and small tasks such as checking and verifying the data on the patient’s insurance card, making phone calls and exchanging emails with the insurance companies, manual data entry and retrieval, maintaining personal information of patients, and several others. With most healthcare facilities still using manual systems for their employees to execute these tasks, the process becomes time-consuming and erroneous.
High overheads: The tedious nature of the process makes it imperative for the management to appoint dedicated specialists and expensive infrastructure to execute the job satisfactorily. Since no provider wants to lose the money they deserve, there’s not much scope of cost-cutting in the insurance verification workflow. For small and mid-sized care facilities, the overheads associated with patient eligibility verification can be overwhelming.
Long turnaround time: Owing to the involvement of multiple tasks, documents, and follow-ups in the submission of the claims and getting them approved, it can take up to several months for the providers to get their dues. So, if the verification is not handled by a team of specialists with adequate experience in the field, the revenue flow of the provider would take a hit and the continuity of operations would be threatened.
Frequently changing policies: The health insurance sector is characterized by rapid changes and modifications of the policy terms and regulations, making it inconvenient for providers to submit claims in the correct format at the first attempt. To get it right and cut down on the processing time, the first step is to adjust the insurance verification process according to the current requirements of the insurer. For this, providers must appoint a specialist who keeps a close eye on the relevant details of the insurance industry to file the claims correctly.
What Happens When You Fail to Verify Insurance?
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3 Easy Steps to Accurate Patient Insurance Eligibility Verification
The insurance verification process is a long one that begins with setting up appointments in advance and collecting patient insurance data beforehand. For impactful revenue cycle management, the verification must be carried out diligently through the following three primary steps.
A thorough process with a checklist
This is the first of the series of steps involved in the verification process that takes place before the patient meets the care provider to decide on the course of the treatment. In this stage, the provider gathers details about the patient such as their name, date of birth, address, and information about their insurance coverage. There is also an investigation into their health and demographic data.
- To be accurate in gathering relevant information, the front office staff of the provider must follow an extensive checklist mentioning with the required fields rather than relying solely on their memory.
- They must connect with the patient’s insurer to verify the coverage details. They should check if the policy covers the diagnosis, procedures, and other services planned for the treatment and if there is a need for a referral or any pre-authorization.
Verifying the insurance card
A genuine insurance card reveals the vital information required to ascertain the eligibility of the patient for the treatment they need. The front office executive can rely on the insurance card to identify the insurance network the patient is tied to.
- Besides the personal details of the patient, the insurance card can be used to establish better contact with the payer/network. The provider can liaise with the payer to know the conditions of getting the claims approved.
- The payer can inform the provider about any coinsurance responsibilities, deductibles, applicable co-pays, policy limitations, documentation, etc. to avoid rejection of claims.
Information sharing with the patient
The office staff of the provider must be well-trained and well-equipped to be able to record the vital details of the patient securely and in the pre-set format. This is so critical because it forms the foundation of the medical claim that the provider would file at the end of the treatment. Any mistake or data error here can lead to payment delays and even rejection of claims.
- Providers must leverage modern technologies such as Robotic Process Automation and cloud storage for accurate data entry, data safety, and easy data access.
- The patient must be kept in the loop and informed about the progress of the verification. Providers must follow-up with them for any concerns or clarifications during the process.
- The patient must be informed about their share of responsibility for the treatment expenses so that they get the time to arrange the money and take the right treatment decision. To maintain smooth collaboration with the patient, most providers use patient portals that facilitate the easy exchange of information to smoothen out the verification process.
Benefits of a Streamlined Insurance Eligibility Verification Services
As an integral part of the revenue cycle management, a well-planned insurance verification practice adds to the financial stability of the healthcare facility while allowing the doctors to focus on their core expertise – patient care. Below is a list of the most significant advantages of adopting a foolproof patient eligibility verification process.
Improved cash flow: Regular cash flow is the lifeline of any commercial institution including healthcare facilities. Keeping the revenue wheel moving ensures unhindered operations and better patient care. When the patient’s insurance policy is verified accurately, providers get a clear picture of the payment responsibilities of all stakeholders and this boosts the instances of clean claims.
Faster payments: For approved and partially approved claims, the payment cycle is long. On occasions, the process even demands rectifications and resubmissions, ultimately leading to undesirable delays. An efficient verification process helps providers stay ahead of the rapidly changing regulatory requirements of the insurance carriers and thus avoid any kind of billing errors to eliminate reimbursement delays.
Patient Satisfaction: In the entire episode, it’s the patient who suffers the most – physically, emotionally, and financially. Hence, besides treating the illness, providers must try to alleviate the payment concerns of the patient by informing them upfront about their payment liabilities. An erroneous assessment can lead to denial of claims, so either the providers lose money or the entire burden has to be borne by the patient, leaving the financially exposed. With no financial burden of the treatment, providers can offer a better experience to the patients and help them recover faster.
Why Outsource Insurance Eligibility Verification Services
Like every industry, the healthcare sector too relies heavily on the outsourcing model for getting the non-core activities handled by external specialists who cost-effectively offer quality services. Patient eligibility verification is one of the processes that care providers usually prefer to delegate to their external partners owing to the several advantages they gain in the process. Some of the primary factors that make outsourcing patient insurance verification to insurance verification services companies are listed below.
A streamlined process guaranteeing better outcomes: An external healthcare services vendor has the right manpower, infrastructure, and processes to entirely transform the eligibility verification workflow. The vendor team specializes in tasks such as document management, follow-ups with stakeholders, and correct processing of files to expedite the claim approvals for their clients.
Fewer denials and delays: Since outsourcing specialists usually submit cleaner claims by identifying and eliminating all inaccurate and erroneous data from the claim forms, the approval rate is significantly high and the payment time is shorter. Competent outsourcing companies keep themselves updated with the latest regulatory policies of the industry and are adept at ascertaining prior authorization requirements to get the claims approved.
Improved patient care: When non-core administrative tasks are handled by experts, the core team finds it easy to focus and improve on their area of specialty. This is particularly true for small and mid-sized care facilities that are usually understaffed and rely on the monthly revenue to keep operations going. The third-party services team helps providers in counseling the patients for the payment (if any) even before the treatment starts. This alleviates the patients’ concerns of being slapped with colossal medical bills at the end of the treatment.
Insurance data management: Since all healthcare records, including insurance details, are confidential, external service providers leverage the latest technology to manage and secure the case documents of the patients. For this, they use Artificial Intelligence (AI), Machine Learning (ML), Automation, and Cloud to protect patient information with the latest security infrastructure and avoid any kind of data loss or misuse.
Scaling footprint: With a reliable partner by their side handling tasks like insurance verification, claims management, regulatory compliance, and the like, the management gets a solid opportunity to scale their operations. Climbing the growth curve gets easier as the vendor helps realize massive cost savings, reduced dependency on in-house staff, and an impressive bottom line.
The journey to a robust healthcare revenue management cycle begins with a solid patient eligibility verification process. But as the process is a drain on the already stretched resources of most healthcare facilities, outsourcing the services to insurance verification companies is the preferred choice for providers around the world. This also plays a key role in offering a better experience to patients since they get a clear idea of their payment share upfront. With technology transforming the face of every major sector, care providers must also choose to tackle the daily operational challenges by embracing modern healthcare solutions and services. When a trusty healthcare services provider is entrusted with critical but non-core processes like patient eligibility verification, the benefits are realized by all stakeholders in the scene – providers, payers, and patients.
Who We Are and Why We Are an Industry Authority?
This article is brought to you by OutsourceRCM, a leading provider of healthcare insurance eligibility verification services to US healthcare providers. With over 10 years of experience in healthcare BPO, we have developed a highly streamlined process to establish accurate insurance information for our clients. Our services have assisted our clients carry out procedures with prior authorizations.
