Mastering Insurance Eligibility Verification - Your Key to Reducing Claim Denials

Why is Eligibility Verification and Prior Authorization Needed?

Eligibility verification and prior authorization are indispensable in the healthcare industry to ensure that the services provided are covered by the patient's insurance plan and that necessary approvals are obtained before services are rendered. These processes prevent unexpected costs for patients and financial losses for providers.

For instance, consider a scenario where a patient arrives for a scheduled surgery only to discover that their insurance does not cover the procedure at the chosen facility. This can result in the surgery being delayed or rescheduled, causing significant inconvenience to the patient and financial loss to the provider. Another scenario could involve a patient receiving a costly diagnostic test without prior authorization. Later, the insurance company denies the claim, leaving the patient with a hefty out-of-pocket expense and the provider with an unpaid bill.

Statistics underscore the importance of these processes. According to a report by the American Medical Association (AMA), administrative tasks related to eligibility verification and prior authorization consume an average of 14.6 hours per physician per week. Furthermore, a survey by CAQH revealed that 86% of claim denials are preventable, with eligibility and prior authorization errors being among the top causes. These figures highlight the critical role these processes play in the efficient operation of healthcare practices.

How it Helps Providers and Patients

For healthcare providers, eligibility verification and prior authorization simplify the patient registration process. By verifying eligibility before appointments, providers can streamline the registration process, reducing confusion and delays. Accurate eligibility verification ensures that the services provided are covered, significantly reducing the likelihood of claim denials. This not only enhances the provider's revenue cycle management but also increases collections, as providers can confidently provide services knowing they will be reimbursed, leading to improved cash flow and financial stability.

Patients also benefit greatly from these processes. They help avoid unexpected expenses by informing patients about their coverage and potential out-of-pocket costs upfront, preventing surprise medical bills. For example, a patient scheduled for a major surgery with verified eligibility and prior authorization in place can proceed with their surgery without any administrative hitches, fully aware of their coverage and costs. Additionally, timely care is ensured, as necessary medical services are approved in advance, allowing patients to receive the care they need without administrative delays. This smooth registration process and clear communication about coverage enhance the overall patient experience, contributing to higher satisfaction levels.

A How-To Guide on Carrying Out Eligibility Verification

Key Steps for Eligibility Verification:

• Collect Patient Information: Gather essential information from the patient, including name, date of birth, insurance ID, and contact details.
• Verify Insurance Details: Contact the insurance provider using various methods (phone, online portals, clearinghouses) to confirm the patient’s coverage, benefits, and eligibility for specific services.
• Check for Prior Authorization Requirements: Determine if the planned services require prior authorization. If needed, submit the necessary documentation and obtain approval before the service date.
• Document Verification Results: Record the verification details in the patient’s file, including confirmation numbers, names of representatives spoken to, and any relevant notes.
• Communicate with Patients: Inform patients about their coverage, potential out-of-pocket costs, and any required actions from their end, such as obtaining referrals.

Ways to Perform Eligibility Verification:

• Manual Verification: Calling insurance providers directly to verify patient eligibility. This method is time-consuming but essential for detailed and specific inquiries.
• Online Portals: Many insurance companies offer online portals where providers can quickly verify eligibility and coverage details.
• Electronic Health Record (EHR) Systems: Integrated EHR systems often have built-in eligibility verification features, streamlining the process by automatically checking patient coverage.
• Clearinghouses: Using third-party clearinghouses that aggregate and provide eligibility information from multiple insurance providers can save time and improve accuracy.

In Conclusion

Eligibility verification and prior authorization are critical tools for managing claim denials and ensuring smooth healthcare delivery. By verifying coverage details upfront, providers can enhance their revenue cycle, reduce administrative burdens, and improve patient satisfaction. Efficient eligibility verification processes lead to better financial outcomes for providers and a more transparent and stress-free experience for patients. Most providers today prefer outsourcing their insurance eligibility verification to a professional medical billing service company as it significantly alleviates administrative burdens and expenses, ensuring accuracy and efficiency throughout the process. Learn more about our patient insurance eligibility verification services.

Introducing BristolBot™ - Rapid Eligibility Verification Solutions

At Bristol Healthcare Services, we continuously try and discover newer ways to simplify and streamline our client’s workflow using the latest tech. Our proprietary eligibility verification software, BristolBot™, is a cost-effective solution designed to simplify and speed up eligibility verification and claim status checking for healthcare providers. Utilizing BristolBot™, providers can save an average of 70% of their expenses on eligibility verification and claim status checking, providing a faster and more efficient way to get reimbursed for services rendered. BristolBot™ also boasts end-to-end encryption and state-of-the-art security, ensuring patient data confidentiality. Our data centers are SSAE-16 SOC-1, SOC-2 certified and comply with HIPAA, HITECH, PCI-Level 1 DSS, and NIST 800-53 standards.

Some of the standout features of BristolBot™ include:

• Multi-Network Connectivity: With over 900 insurance providers in our network, fetching and verifying patient insurance information is effortless, efficient, and quick.
• Effortless Log-in: Verify insurance coverage with a single username and password, eliminating the need for multiple user accounts for various payers.
• Batch Uploads: Check the coverage details of multiple patients at once by downloading your patient list and uploading it to BristolBot™, receiving results in just a few seconds.
• Real-Time Verification: Obtain coverage details – active, inactive, specific benefits, and more – in just 3-5 seconds, ensuring patients don't have to wait.
• Hassle-Free Claim Status Check: Instantly check the status of multiple claims with our ‘batch mode,’ and use our claim status trend feature for root cause analysis to prevent future denials.
• Security & Safety: BristolBot™ prioritizes the safety and security of your practice and patient data (PHI), with certifications and compliance ensuring the highest standards.
• No Installation/Maintenance: BristolBot™ requires no installation or maintenance overhead, always providing the latest version of the software.
• Multi-Device Support & User-Friendly: Access BristolBot™ from any device – desktop, laptop, tablet, or mobile – with an easy-to-use interface that displays information clearly.

By leveraging BristolBot™, healthcare providers can streamline their eligibility verification and claim status-checking processes, resulting in improved collections, reduced administrative workload, and enhanced operational efficiency. Learn more about our insurance eligibility verification software.