Nuances in Eligibility Verification

May 16, 2023

The healthcare industry is constantly changing, and healthcare providers must keep up with the changes to remain compliant with various regulations and stay updated on best practices. One of the key areas in which providers need to keep up-to-date is eligibility checking. Eligibility checking is a critical process that helps ensure patient bills are paid correctly and on time. It’s essential for all healthcare providers to understand the nuances of eligibility checking to proactively avoid costly billing errors.

Before each patient's encounter, it is best to ensure:

1. Does the patient have insurance coverage?

Verify whether the patient's insurance ID is valid and active with the Insurance carrier. If your automated system cannot confirm, contact the patient for more information, and re-verify if the information differs. Contact the Carrier for details if your system cannot verify it.

2. What is the plan?

Even though coverage may show “Active”, each plan has specific coverage. It is important that you focus on the Covering Plan rather than the insurance company. For example, UHC is now an umbrella company that offers hundreds of plans. Plans can vary in coverage significantly. Medicare and Medicaid managed-care plans differ significantly from straight Medicare and Medicaid plans.

Each plan may have a different contracted rate for the same CPT code. It is essential to be aware of the Plan’s contract rates. If not, it is better to verify with Carrier.

3. Is the scheduled provider a participating provider? In-network or Out-of-Network?

It is essential to verify the provider's participating status. It is no longer straightforward like “we participate with UHC”. It is provider specific, plan-specific, and location-specific.

4. Are specific CPT codes covered today for the scheduled provider?

Each plan has different coverage rules for the same CPT code – if you are unsure, check with Carrier. Also, each CPT code’s coverage may depend on the number of visits per calendar year and based on the diagnosis. Some may require pre-authorization.

5. Are previous visits getting paid as expected?

It is better to review the patient’s ledger to flag any potential coverage denials happening with the patient’s insurance so that they can be addressed immediately before building up potentially unpaid balances.

6. What are the co-pays, co-insurance, and deductible?

Determine what the patient owes today. It is dependent on visit type (or CPT Codes). Some carriers provide an estimate of the deductible balance left in the current calendar year. Use these estimates to determine what needs to be collected today (along with any past-due balance).

Eligibility checking is a key part of any successful medical practice’s business strategy, as it helps you maximize reimbursements, reduce write-offs, and avoid costly billing mistakes. It is vital to make sure patients understand their coverage and their financial responsibilities so that the practice is not left with unpaid bills down the road. With the proper knowledge and tools in place, you can easily track patient eligibility quickly and accurately, ensuring your practice stays ahead of the curve when it comes to managing reimbursements while providing quality care for your patients.

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