Medical insurance verification plays an important role in assisting a provider get in paid in full. It validates the policy, establishes the patient’s credentials and authorizes the provider to render the service.
Many providers carry out this service with the help of medical insurance verification software. The problem with these tools is that it has to be updated with any change in rules. Therefore, relying on tools cannot be a fool-proof way of carrying out complete insurance verification.
The patient insurance verification process requires a call to the insurance company to verify every aspect of the coverage. One such call must make the most of collecting all the necessary information required to ensure a clean settlement of claims.
Important Things to Keep in Mind to Make an Insurance Verification Call a Success
The following are the things that are to be made note off while reviewing an insurance policy or making an insurance verification call:
Policy carrier
Knowing about a policy carrier is very important. This is because each policy carrier frames their own rule within the guidelines formulated by insurance regulatory bodies. Knowing the policy carrier gives you an instant idea of the rules to be met. Some providers even have separate teams to handle different insurance carriers. Therefore, knowing the carrier helps you to route it to the right department.
Policy Status (Active or lapsed)
This is arguably the most important aspect of insurance verification. You need to enquire about the active or lapse status just to make sure you get paid for the services rendered. Many insurance holders miss out on insurance payments and approach providers after the coverage has expired. Therefore, it falls upon you to check that the coverage is active before you deliver services.
Type of plan
Knowing about the insurance plan is important because different plans have different types of coverages. Different plans have different share of costs for an enrolled person. Likewise, different plans have different deductible rates. Deductibles are the amount one pays before the coverage of a plan kicks in. It varies according to plan. The least expensive plan carries the highest deductible and vice versa. Knowing the type of plan will help you convey to the patient how much they need to bear upfront.
Coverage Provided by Different Health Plan Categories· Platinum plan: Covers 90% of the medical costs; 10% is borne by the patient · Gold plan: Covers 80% of the medical costs; the patient pays 20% · Silver plan: Pays for 70% the medical costs; rest 30% is paid by the patient · Bronze plan: Covers 60% of one’s medical costs; the patient has to pay 40% · Catastrophic plan: Catastrophic policies come into play after one reached a specific deductible. It covers the first three primary care visits and preventive care for free, even if the deductible hasn’t been met. |
Maximum Age covered
Every policy covers a person up to a certain age. This again differs from plan to plan. Therefore, ascertaining the patients age during insurance verification process is important. If not a provider may end up providing services to one who is over aged. This would lead to denial of claims. The easy way to ensure this doesn’t happen is to have a checklist for each carrier and plan ready.
Family members covered under the policy
A policy may not have all family members covered under it. A policy meant exclusively for family members may exclude grandparents. Likewise, there are plans only for husband and wife and which does not cover a new born. Ascertaining this during the insurance verification stage is important.
Policy owner’s contact credentials
Medical insurance eligibility verification must also seek to establish the credentials of a person seeking coverage. This is because many people try to impersonate to seek claims. Therefore, contact details of the seeker must be mapped with the policy. This includes, their cell phone numbers, address, social security number, age, sex etc.
The Benefits of a Robust Health Insurance Verification Process1. Improves Cash Flow: Insurance verification helps in submitting clean claims. This ensures all claims are processed faster and the outstanding amount is recovered in full. 2. Reduces rejections: A proper insurance verification process helps in meeting payer guidelines correctly. This leads to a reduction in rejections and denials from the insurance companies. 3. Controls Bad Debt: Most outstanding dues get converted into bad debts because of failure to recover them on times. This can be checked by appropriate insurance verification. 4. Keeps Patients Satisfied. Insurance verification helps keep patients informed about their payment responsibility in advance. This advance knowledge eliminates anger and frustration. 5. Improve Bottomline: The overall impact of a robust insurance verification process is enhanced bottom line. This puts a provider in the trajectory of growth. |
Coverage details
Knowing the complete details about a coverage is an important requirement before providing coverage. The coverage details will tell you what diseases and services are included and what are excluded. Not all plans cover all diseases. Some plans even have a specified waiting period. These must be looked into meticulously to avoid claims denials.
Co-pay details
Co-payment helps a provider collect money in full. In fact, copayment is the percentage of the claim that the patient has to pay on his own irrespective of the claim amount. And the balance is covered by the carrier. The knowledge of this helps a provider collect the patient’s part of the payment upfront. This reduces their accounts receivables.
Pre-existing diseases clause
Some diseases are not covered by carriers if it happens to be a pre-existing. This is clearly mentioned in the policy clauses. So, as a provider you need to know about the pre-existing that are excluded from coverage in the plan or requires a waiting period. This again is crucial or it may lead to a rejection.
Pre-authorization and claim submission
Pre-authorization is a critical task accomplished by proper insurance verification. It involves ascertaining with the insurance provider that a particular procedure is covered for payment. It also involves updating the provider about a process being carried out. Many procedures require pre-authorization. Failure to obtain can lead to claim rejection.
Referrals
Referrals are like recommendations that are made from one physician to another. Insurance policies require patients to obtain the original referral from their doctor. A formal script from the doctors may not suffice. There might be a need for referral from the insurance payer. The referring doctor’s office would move the insurance payer to provide the patient with a referral number. This referral number is mentioned while submitting the claim.
Who We Are and What Makes Us an Expert?
We at MedBilling Experts are providers of back-office support to hospitals and clinics in the US. We have an experienced and dedicated medical billing team specializing in insurance verification services. Our team collects all the necessary information on behalf you and validate it before the patient’s treatment starts. We help you get all the necessary referrals and prior authorization codes. Our well-developed process helps us stay on top of carrier rules and policies. This makes our insurance verification process neat and complete. If you are looking for one of the best insurance verification companies get in touch with our experts now.
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