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Eligibility Verification in healthcare RCM

Regarding accurate eligibility verification in healthcare RCM, there are several options – all of which impact the revenue stream in one way or another. The primary concern is how much the mode of patient verification ahead of time improves the payment rate for providers. Furthermore, the next consideration is the amount of time employees must spend in the verification process – manual verification costs more in terms of employee time than electronic verification. Revenue cycle management efficiency depends on efficient patient eligibility verification – let’s understand its impact.

Patient Eligibility Verification in Healthcare RCM and Its Impact on Payments

There are a few ways in which patient eligibility impacts the time practices need to wait for full payment of their services; these include:

  1. Verification of patient coverage in advance lets the practice estimate the actual and total patient responsibility for payments. When patients are informed regarding their estimated total before the appointments, they are more likely to show up to the appointment ready to pay their share or make payment plans.
  2. Sometimes, patients are incorrect regarding their coverage. Insurance information is confusing for patients and also changes rapidly. Most patients aren’t aware of the changes in their deductibles and any other aspects impacting the amount of money they need to pay. Here, the value of eligibility verification in RCM is vital to inform patients as soon as possible so they can budget the extra costs or find ways to work with the practice to create custom payment schedules. Patients do want to pay their bills on time. Thus, the patient eligibility verification process lets practice help patients gather all the required information to avoid being blindsided by large medical bills.
  3. Furthermore, eligibility verification in healthcare RCM also helps protect physician practices when insurance has lapsed, or policies do not cover the services.

Benefits of Outsourcing Authorization and Eligibility Verification in Healthcare RCM

The many benefits of eligibility verification in healthcare RCM include:

Cost Effectiveness

An in-house team solely working on insurance-related operations imposes a financial burden on provider practices. Recruiting staff, training and retaining them, and investing in the necessary technology/software can balloon costs. Outsourcing insurance verification tasks effectively eliminates all of these overhead expenses. Professional outsourcing providers offer flexible pricing models, facilitating you to pay for services as needed. The cost-effective solutions ensure that your practice resources are utilized efficiently.

Specialized Expertise

Outsourcing lets you freely tap into the expertise of specialized professionals. The expert and professional teams are full of in-depth knowledge and expertise to navigate the intricacies of insurance plans, policies, and operations. By outsourcing services from experienced billing providers, you gain access to their pool of industry-specific knowledge and thus can ensure efficient and accurate claims processing.

Improved Efficiency

Outsourcing eligibility verification in healthcare RCM frees up valuable time and resources that can be used in your practice. Instead of having your staff juggle multiple responsibilities, they focus more on your practice’s core operations, including patient care and practice revenue generation. With a professional team handling your revenue cycle management process, you can:

  • Streamline operations
  • Reduce administrative burdens
  • Boost overall efficiency

All of this results in a smoother and faster revenue cycle, leading to better cash flow and reducing claim denials.

Flexibility and Scalability

With your growing practice, the volume of insurance verifications and authorizations will surely increase. Medical billing outsourcing companies, a.k.a. the third-party billing companies, have the scalability and resources to manage fluctuating operations/workloads, thus ensuring prompt processing without compromising quality. Be it your practice needing assistance during the peak periods or ongoing support, outsourcing to a third-party billing entity offers you the flexibility to adapt to changes in needs. Furthermore, you can also scale up your operations without the hassles of training or hiring additional staff.

Compliance and Accuracy

Insurance requirements and regulations are subject to constant change. Keeping updated and compliant with these changes is challenging for the in-house teams. Professional providers specialize in authorization and eligibility verification in healthcare RCM. Furthermore, the third-party providers have a keen understanding of the industry regulations. Such providers have the latest technological knowledge to ensure accurate verification, authorization, and claims processing. All of which reduces risks of rejections, errors, and compliance issues.

Advanced Technology

Outsourcing partners use advanced technologies to streamline the verification processes, cut administrative expenses, and thus increase overall efficiency. Technological advancements facilitate the automation of the verification processes, thus reducing administrative costs and boosting efficiency.

Improving Cash Flow

Eligibility verification in healthcare RCM helps improve cash flow by reducing the number of claim rejections and denials. Upfront verification of insurance information reduces the likelihood of denials of unpaid claims.

Minimizing Denials and Maximizing Reimbursement with Eligibility Verification

An insurance verifier is a person who ensures smooth operations. They are an integral part of the staff. Insurance verifiers work with the patient, handle all the paperwork, and verify patient information with insurance carriers. Their role is vital for facilitating the entire RCM process, thus maximizing reimbursements.
Insurance verifiers work to verify the following:

  • Co-pays
  • Patient policy status
  • Co-insurances
  • Claims mailing address
  • Referrals & pre-authorizations
  • Payable benefits
  • Deductibles
  • Effective date
  • Type of plan and coverage details
  • Plan exclusions
  • Lifetime maximum, and more

Steps of Insurance Eligibility Verification Process

  • Get payment schedules from practice/hospital or clinic
  • Start verification of a patient’s insurance coverage
  • Get in touch with the patient for additional information if and when required
  • Update the billing systems with all the necessary verification and eligibility details. These details can include:
  1. Start and end dates of patient insurance plans
  2. Member ID
  3. Group ID
  4. Co-pay information, and more.

Final Word

Outsourcing eligibility verification in healthcare RCM can assist healthcare providers in maximizing their revenue growth. Outsourcing ensures that practice is billing accurately and appropriately so healthcare providers can focus on their core competencies. Offering high-quality patient care leads to increased patient satisfaction and loyalty.

Frequently Asked Questions

Charge entry is a process or even a set of processes that changes for medical services and other patient-related services that get submitted to appropriate payers for billing and reimbursements.

Eligibility verification in healthcare RCM is the process of verifying a patient’s insurance in terms of:

  1. Coverage status
  2. Active or in-active status
  3. Eligibility status
The healthcare insurance verification process is where a medical billing team determines a patient’s insurance coverage for medical services rendered, in addition to a patient’s financial responsibility. Your medical billing staff must complete insurance verification before even scheduling services.