Benefit Eligibility & Verification

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

Depending on your practice, eligibility can mean many different things to many different specialties. However, the key to a strong revenue cycle and patient collections strategy begins with eligibility verification.

Basic Eligibility

What is basic eligibility? This is checking with the insurance company ahead of the patient’s appointment to make sure they still have an active policy. You may have personnel dedicated to that task 2-3 days ahead of your scheduled appointments. However, most EHR’s and Clearinghouses combine to offer basic eligibility checking in your system. This automated process does a simple eligibility check, usually in the middle of the night, and verifies if the patient has active insurance. With this process, you can reduce the number of staff needed to check eligibility down to 1-2 employees following up only with patients that do not have an active policy.

Specialist Eligibility

If you have a specialist practice, you typically need a little more than the standard “Does this patient have insurance” eligibility verification. This may require a little more research for staff members. Is a referral needed for the patient to come to your practice? Does the patient need a pre-auth for a medication? You may need to have your staff working directly on the payor’s website for extended benefits information.

Surgical Eligibility

If you are a surgical practice, you are going to need in-depth benefits and eligibility verification. You will need to know what the patient responsibility is going to be, confirm the surgical CPT code is covered under the patient’s plan, and if an authorization is required, that the location, surgeon and CPT code are covered under that authorization. The key here though is what the patient responsibility portion of the surgery will be. The key is to have your fee schedules handy to be able to calculate exactly what the patient will owe and collect as much as possible up front to prevent issues with collecting patient balances later on.

While it seems simple, the top denials and rejections we see in this industry tie back to insurance benefit verification. A little work up front will save a lot of your billing team chasing down money to collect on your AR.

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