Why Eligibility Verification is Essential for Medical Billing Companies?

When there are several factors for a claim to get denied, missing out on eligibility verification can put medical billing companies under great trouble. Very importantly, eligibility verification is a way to check if the claims escape denials with actual coverage ability. If you are unsure about the facts that lie within the coverage policies, it’s lame to discuss whether the claim would reach to the boarder of reimbursements.

In the recent years, medical billing companies are specially focusing on the eligibility verification to avoid further issues connected to the policies of the insurance companies and the patient. Not everyone who has insurance policy is eligible for all the healthcare services. There are few that cannot be covered under certain policies, and that’s what every healthcare professional must watch out for!


Verification of Eligibility and Benefits in Medical billing Companies:

  • According to sources, two of the top five claim denial reasons are for insurance-coverage related issues.
  • Several claims are denied due to expired eligibility of the patient or because the service was not covered by the plan in question. Having a strong insurance verification process can reduce similar types of denials in the healthcare practice, making medical billing companies more efficient and raising the overall bottom line.
  • Insurance should be verified prior to the clinical services and should never be a task the medical billing staff handles on the back end. Follow these five steps to reduce the chance of eligibility-based denials.

Insurance Verification Check-list:

  • Ask the appropriate questions during the insurance verification. Medical billing companies or the office staff should enter information gleaned from the insurance card, phone calls with the insurance company, or electronic eligibility systems. Insurance eligibility verification information in each patient’s electronic medical record for your practice should include the following:
  1. Insurance name, phone number, and claims address
  2. Insurance ID and group number
  3. Name of insured, as it isn’t always the patient
  4. Relationship of the insured to the patient
  5. Effective date of the policy
  6. End date for the policy
  7. Whether coverage is currently active
  8. Whether the insurance covers the procedure, diagnosis, or services to be provided
  9. Whether your practice participates with the plan
  10. Limitations of the policy, including exclusions or documentation requirements for bills
  11. Whether a referral, pre-authorization certificate of medical necessity is required for payment
  12. The amount of the patient’s co-pay and deductible

Try to get a copy of the patient’s insurance card:

  • Start the process by collecting insurance eligibility verification information by asking for a copy of the new or renewed information form that particular patient.
  • It’s always a better idea to ask for a copy of the card even if the patient states that insurance hasn’t changed.
  • An updated image of both sides of the insurance card in your electronic health record provides informational backup in case someone missed to put the insurance information into the record. Medical billers or healthcare professionals should double check ID numbers against cards before sending claims.

Contact the Insurance Provider:

  • Don’t accept the information on the cards bluntly. Even a few weeks after a card is issued, insurance coverage or the policy might have changed or been discontinued.
  • Always remember to contact insurance companies directly to ensure eligibility. Have a phone call with the insurance payer or use the integrated EMR and the billing system to connect with large insurance companies such as Medicaid, Medicare, or Blue Cross for eligibility data.
  • When one can set up electronic eligibility systems for payers, it might not be the most efficient option. Healthcare professional must be able to import data directly into electronic medical record systems, making the process even faster and avoiding possible data-entry errors.

Record very accurate information:

  • Offer your claims to the medical billing companies or train the office staff to pay extra attention and care while transcribing information into the patient record. The information builds the foundation of the medical claim, and a single transposed number can mean the difference between a clean claim and a denial.
  • It’s not recommended to rush through the insurance verification practices and make data errors because they may cause days or weeks of delay on payments. The claim could even go completely unpaid, which is bad for any medical practice.

Follow up with the patient whenever necessary:

  • In case there are few concerns and questions, follow up with the patient regarding insurance information.
  • Use a patient portal in order to inform patients of eligibility through email or efficient online communication. But office staff can also call the patient to let them know about co-pays or other issues.
  • Inform the patients as early as possible about out-of-pocket expenses. This increases the chance to collect those funds.


Types of Eligibility Verification Processes Follow:

There are two types of eligibility verification processes.

Basic Verification Process:

  • Under the basic verification process, the eligibility timeline is verified, which includes effective coverage dates. Additionally, it also includes the patient details including name, address, contact information, claim limits, pre-existing criteria and plan types. The basic verification also gives information on whether the provider is within the network or out of network.
  • Complete details are entered into the insurance eligibility verification form. Apart from the verification process, the co-pay, co-insurance, dependent insurance, and other deductibles are also confirmed.
  • This particular type of basic insurance verification process is recommended for a smooth healthcare process, as some patients who renew their policies in the first quarter may not do so in subsequent quarters and hence may not be eligible for insurance coverage.

Advanced Insurance Verification:

  • For the advance verification, all the steps under basic insurance verification are to be completed.
  • Additionally, few other details including renewal rate frequency, yearly or monthly, are to be included.
  • It also records details including health fund usability, i.e. the amount of insurance that has been utilized of the total allocated for the year. Similarly, co-pays for the tests, lab fees, and pre-certification are documented. Under this process, even inclusions and exclusions are verified.


Outsource the eligibility verification to the best medical billing companies to prevent denials and revenue loss. To know more about medical billing companies, please subscribe to our blog. Visit our social media pages to learn more about healthcare billing.


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