Delphi Medical Billing

4 Important Patient Eligibility Verification Qualities

Suppose your practice has cared for the same pleasant patient regarding her rheumatoid arthritis for 13 years. This particular patient is never late for her appointments and has never missed paying her patient balance in full. Taking this hypothetical scenario further, suppose she checks in today for a routine follow-up appointment and a refill on her long-term steroid medication. Your office personnel sees her insurance carrier is the same as her last appointment, so they don’t see the need to verify her insurance. However, what if her insurance carrier has changed ownership and some of their co-pay policies have changed? What if she simply forgot to inform your office that her employer changed coverage options for her and her co-workers?

We will delve into four important patient eligibility verification qualities to exhibit all the time, every time.

Follow the Rules

Medical providers in some clinics feel that waiving a copay for patients is doing them a favor. It isn’t. First of all, waiving a copay could possibly harm a patient when insurance companies reassess co-pay rates and a discrepancy is discovered, or the patient is hit with a dreaded “running balance.” More importantly, a copay must be paid, by law, and can’t be written off.

Writing off co-pays or deductibles technically breaks the physician to insurance contract and the patient to insurance contract, simultaneously. The only way to ensure your office is always collecting the appropriate co-pay is by verifying the correct, most up-to-date patient eligibility information at every single visit.

Stay Ahead of the Problem

Studies have shown that up to 30 percent of claims are ignored or denied on first submission. A large portion of these rejected claims are simply because the incorrect demographic information – especially accurate insurance carrier information – was recorded, if at all. Beyond that, if a patient isn’t eligible for a specific medical service, it is much better to let them know up front rather than have the patient be angry about a bill on the back end.

The only way to quell this problem is to have your office personnel ask for updated insurance info every time a patient comes in, or by using a patient portal online before every visit. Simply asking if a patient’s insurance carrier has changed might miss when patients forget about insurance changes. Therefore, make sure your office personnel or your outsourced medical billing team has a solid protocol set up for getting this information accurate every time.

Be Upfront

It can seem insensitive to discuss finance in great detail before a patient has received the care they need. However, patients tend to feel much more involved, and certainly less blind-sided, when they know upfront about their actual benefits and financial responsibilities in advance of rendered services. Of course, the only way you can have an informed discussion about this is by verifying that a patient’s insurance eligibility is absolutely up-to-date and accurate.

Stop the Dominoes

Think of your practice’s revenue cycle management as a long unbroken chain, where any interruption inevitably damages all the subsequent steps. If insurance eligibility or carrier specificity isn’t verified accurately for a patient visit, this can have a domino effect: the claim will get denied, decrease practice revenues, increase days in A/R, and decrease collections of deductibles, copays, and co-insurance. Remember, rectifying this situation worsens these problems exponentially in terms of time lost, trying to collect monies owed and turning in a clean claim. In some cases, even the physical cost of resubmitting claims can be expensive; it’s a drain on your in-house billing staff whose resources could be used elsewhere.

While some practices feel detailed financial explanations and verifications at every visit will cost their practice time and effort needed to execute, this can pay off much more in the end. Setting up a system that trained office personnel can employ, or a protocol with an outside medical billing service you use (recommended), can be the difference between a claim being accepted or denied.