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Importance Of Eligibility And Insurance Verification And Their Steps

by BillingFreedom | Apr 17, 2024

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The healthcare space currently has created a lot of confusion about health insurance. This is not just the case for healthcare providers. But also, for patients.

Most patients are totally unaware of the specifics of insurance. They might not know much about the mechanism behind it. This is the case because insurance comes with numerous cost–sharing options. Chances are they do not even know the difference between premiums. Co–pay. Deductible. Co – insurance. Or out of the pocket maximum. All of these span health coverage.

Patients can sometimes become confused. About the payment methodology. For instance, why do their plans come with higher co-insurance? Even though they have opted for an extremely low–cost premium plan?

Having once negotiated lower payment rates. They naturally feel cheated out of their money when they have to pay more. Especially when an out-of-network service takes up their bill.

And if they are denied coverage. It would simply add to the bafflement. Because they might not be realizing that they have not met the deductibles. Research reveals that most of the claims are denied. Or even delayed. Are done so because there exist critical gaps in patient information.

This can be owed to a number of different reasons. For example, incorrect filling of forms during their visit to the provider. Failure to bring the medical dossier of the patient up to speed at the front desk, or reception. Expiry of particular insurance coverage. Missing claim forms. Mismatches between the service that has been provided and the diagnosis. Or a lack of pre-certification, etc.

To avoid claim denials. And ensure smoother revenue cycle management. The insurance eligibility and verification process need to be extremely effective.

Why Insurance Eligibility Verification Is Important

Insurance eligibility verification is the procedure of verifying a patient’s insurance. And all relevant information. It includes coverage status. Active or inactive status. And eligibility status.

Lacking this information. Health care services can go completely off track. Insurance eligibility verification is directly linked to claim denials. Or any other payment delays in the system. Inaccurate information merely adds to the excessive backlog of account receivables.

Verification needs to be carried out step – by – step. Articulately and precisely to ensure an error free experience. Some of the steps detailed below might shine further light on the absolute importance of insurance eligibility verification.

Steps Pertaining To Insurance Eligibility Verification

Scheduling Patient Appointments

Patient scheduling at certain practices is still a largely manual process. Phone calls and active engagement can still sometimes lead to fallouts in gathering the right information. Using automated appointment scheduling software can be a game changer for your practice. This software allows patients to self – schedule online. And automatically prioritizes appointments. This enables the process to become far more streamlined.

The software can also go a step further. And set up appointment reminders. Those are generated and emailed. Or even texted to the patients. This would include waiting lists., And Rescheduling. Making the act much faster. And more accurate.

Patient Enrolment

Patient demographics are part of the vital data present in a health care facility. The main priority is what is to be added. And what is to be omitted. For example. Identification. Which includes details such as name, date of birth, and address which are imperatives. As well as the diagnosis. Any prior allergies. Medical history that stands out, etc.

However, information such as the patient’s emergency contact. Family doctor. Insurance provider. Among other things, may be categorized under separate means. As they answer the not – so pertinent questions.

Verification Of Eligibility

This is by far, the most ignored part of revenue cycle management.             When done right, eligibility verification can increase the number of clean claims for your practice. Given that the verification process goes smoothly. Numerous, serious issues such as delayed payments, denied claims, rework. Decreased patient satisfaction. Increased errors. And non – payment could be forestalled. And properly addressed.

In short, it would save you a whole lot of hassle. And bring in more money, quicker, for the practice. Strong financials should always be a priority for a practice.

If you should choose to outsource your billing department. It should be to one of the best medical billing companies in your region.

Coverage And Benefit Verification

For each patient. It is vital to check, periodically, the coverage and benefits that have been extended under the insurance plan of a patient. In order to ensure this, accurate patient information is a must-have. Any changes such as birth, divorce, etc. could change the coverage as well as the benefits.


Pre-authorization is always a good idea. This refers to obtaining authorization from the payer for a treatment, before it happens.

Reaching Out To Patients

This refers to the process of reaching out to certain patients who may not have provided their full information. It is a follow-up.

Updating The Billing System

The billing software will require patient details to be updated. For instance, patient coverage.

How To Optimize The Insurance Eligibility Process

To insure the process works out seamlessly as ever, listed below are some of the tips that can be used for a better insurance verification process.

Checking Regularly

This falls under checking up on patient appointments. And other scheduling done through the scheduling software. Or manually. Depending on the practice.


This is where you take the responsibility of educating patients of their responsibilities. And making them more aware of the payment process. You talk to them about their coverage and financial obligations.


A consistency in verification. This means verifying the patient’s coverage by committedly contacting the insurance executives through calls. Checking out insurance portals. Or even using Interactive Voice Response.

Updating Information

Bringing information up to speed is crucial. Any new, relevant patient information should immediately be fed into the information system. The billing team should be collecting all relevant details, and get the eligibility verified. They should be mentioning co-pay, claim details, and coverage period.

An Efficient Front Desk

The front desk should too, follow up on patient details and check all issues arising with reference to insurance eligibility. The problem should be immediately picked up. And resolved instantly to avoid further denials.

These are tasks that some of the best medical billing companies will handle for you. It’d remove the financial burden off your practice.

BillingFreedom is a top tier medical billing company, committed to customizing solutions for your practice. We improve your cash flow through enhanced revenue cycle management services. A skilled team caters to your hurdles, ensuring full transparency throughout the process.

Call us now:Call us855-415-3472

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