What Methods Can Be Used To Verify Patient Eligibility?

What Methods Can Be Used To Verify Patient Eligibility?

Ensuring the verification of insurance coverage prior to rendering clinical services is imperative, and it is recommended that billing staff refrain from handling it as a post-facto responsibility. To mitigate the frequency of eligibility-based denials faced by your billing team, it is recommended to adhere to a few proven steps. 

Completing an insurance verification checklist

Posing the correct questions during the insurance verification process is crucial. The office staff must accurately record all data garnered from the insurance card, phone conversations with the insurance company as well as available data retrieved through existing electronic eligibility systems. 

The insurance eligibility verification data for any patient's electronic medical record must consist of 

  • The insurance name, phone number, and claims address
  • Insurance ID and group number
  • The relationship status of the patient with the insured person
  • Date of the policy coming into effect and the end date
  • The policy is currently active or not
  • Services and procedures covered by insurance
  • Is the dental practice a participant with the insurance company and plan?
  • Policy limitations and exclusions or documentation requirements for billing procedures
  • Patient copay and deductible amounts

Retain a copy of the insurance card

Initiate the procedure of gathering insurance eligibility verification data by requesting the patient to provide a copy of their updated insurance details. It would be prudent to request a duplicate of the card irrespective of the patient's affirmation of insurance unaltered status. 

Equipping the electronic health record with an up-to-date depiction of the front and back of the insurance card serves as a valuable resource to prevent potential inaccuracies resulting from inadvertent typographical errors in the insurance details. 

It is recommended that dental billers take the necessary measures to ensure accuracy in claim submissions by verifying patient ID numbers against their respective insurance cards.

Get connected with the insurance provider

It is advisable to carefully assess and verify the accuracy of information provided on cards rather than simply accepting it at face value. Insurance coverage can be subject to change or discontinuation within a few weeks from the date of issuance of a card. It is advisable to establish direct communication with the insurance provider to verify one's eligibility. 

To obtain eligibility data, it is recommended to either access the provider hotline provided by the payer or utilize an integrated EMR and Billing System to send a request to larger payers. Implementing electronic eligibility systems for payers represents a highly effective solution. 

Direct import of data into EMR (electronic medical record) systems is a viable option that can potentially expedite the process and eliminate any potential errors associated with manual data entry. 

It is customary for a dental care recipient, whether new or returning, to furnish an insurance identification card when visiting a healthcare provider under routine conditions. It is advisable for the front office to verify the accuracy and currency of the insurance carrier details mentioned on the card.

Accessing the insurance carrier’s website is also crucial to garnering such essential information. An alternative approach would be to contact a designated representative of the insurance provider. There exist designated clearinghouses and advanced practice management systems that can effectively conduct real-time verification of patient eligibility.

Verify Authorization

One needs to only confirm if an insurance policy is in force at the time of services and confirm the patient's financial responsibility. At times, there might be a need for a referral or pre-approval for a specialist's services.  should be confirmed. 

Also, it is advisable to be cautious of the deadlines and always submit the claims as soon as possible. One must note that the documentation provided can vary from plan to plan. Hence, the staff needs to ensure that all referrals are documented in the patient’s records. 

Patient follow-up is important

Follow-up on the patient's insurance information is needed to resolve any queries or worries. Although it is effective to use a patient portal for email or online communication to inform patients of eligibility, office staff can also call the patient to inform them of copays or other concerns. The possibility of receiving these amounts increases when patients are informed at the earliest about out-of-pocket expenses.

Information capture must be precise

Provide training to the office staff to exercise added caution while documenting information in the patient's medical record. The information forms the basis for future claims. A single misplaced digit could spell the difference between a claim and a denial. 

Failing to duly perform insurance verification procedures and committing inaccuracies with data could potentially result in prolonged payment processing or even claim rejection, which could have adverse consequences on the financial sustainability of a healthcare practice.

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