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The Value of Eligibility Verification in the RCM Process

There is no doubt about the seriousness and value of eligibility verification in RCM. Plus, there are a few options available for verification of patient availability, and all of them, in one way or another, will impact the revenue stream in varying ways. The primary concern is how well the mode of patient verification beforehand shall improve the payment rate from both patients and insurance providers. Another consideration – especially on the accounts of prompt medical billing services – is the time spent in the verification process. For what’s worth, outsourcing healthcare RCM and its related operations is a better option than catering these processes in-house, where manual verification can cost a lot in terms of employee time, in contrast to electronic verification.

Value of Eligibility Verification in RCM

It is unavoidable for healthcare practices to overlook the value of eligibility verification in RCM – as it would mean massive revenue leakage and a stack of unprocessed claims. Provider practices need experts with sufficient industry knowledge of the entire process – with hands-on experience handling the whole patient eligibility verification process.

Eligibility Verification in Healthcare RCM

Considering the value of eligibility verification in RCM – A patient’s insurance verification process must take place before their visit or admission to the medical facility. Doing so can eliminate instances of claim rejections and introduce hassle-free processing of the upcoming steps. If the claims face rejection at the first submission, it gets tiring to file them again and might lead the practice to a dead end for payments.
Considerations for Patent Eligibility Verification Process
The three essential considerations include:

  1. A patient’s percentage of coverage for the diagnoses or treatment
  2. Patient’s liability to co-pays and coinsurance
  3. Requirements of pre-authorization for treatments and medication

Steps to Eligibility Verification Process

Let’s discuss the important steps in the eligibility verification process:

Collecting Accurate Patient Information

Eligibility verification teams must determine if a patient’s information is correct and make the necessary changes if needed. Even the tiniest errors lead to claim rejections; therefore, the teams need to buckle down to obtain accurate patient information.
The general patient information includes:

  • Patient name
  • Insurance ID
  • Claims address
  • Name of the insured
  • Group number
  • Start and end dates of policy, and so forth.

Checking-in and Communicating with Payers

Insurance cards do get discontinued for a multitude of reasons – or there can even be new policies added. The value of eligibility verification in RCM necessitates ensuring that the healthcare practices are all well-aligned with the new and updated information. For that, they all must call the insurance provider and confirm the status of a patient’s insurance card. Furthermore, RCM providers and practices can connect with the larger insurance companies via EMR. Electronic communications systems have shown efficiency in almost every industry for streamlining operations. Such systems can process medical records and other important data without any errors taking place. Plus, this can be cross-checked by insurance companies for further confirmation.

Patient Follow-up

For patients’ out-of-pocket expenses, it is essential to contact them and offer them the necessary details so they can make arrangements for the payments. Additionally, if there are any other concerns regarding stored information, the practices shall note it from patients at regular intervals. Moreover, telephone communication seems ineffective and rather mainstream; therefore, online patient portals can be put to use. Doing so allows effective communication for both parties to come to terms with what must be done.

Benefits and Value of Eligibility Verification in RCM

Enhanced Reimbursements and Reduced Denials

The patient verification process ensures easy and smooth checking of insurance eligibility and corresponding benefits. Verification plays an essential role in determining a patient’s eligibility. Verifiers handle all associated activities with patient verification by closely working alongside patients. The entire process helps in attaining higher reimbursements with a reduced number of denials.

Clean Claims

Verifying the use of accurate information for the claim submissions will ensure that all claims are free from any rejections owing to the demographics or co-related errors. Such practices facilitate healthcare practices and the RCM staff in submitting clean claims, which results in increased collections and enhanced patient experience.

Enhanced Cash Flow

The unceasing array of clean claim submissions, reduction in denials, and improving patient satisfaction levels increase cash flow. Boost in cash flow essentially means a steep decline in unpaid claims, effectively raising practice revenue streams.

Improving Workflow

The value of eligibility verification in RCM can also be understood by seeing considerable improvements in the workflow. How – the process as a whole involves putting information together in a streamlined manner. Essentially, doing so helps improve the RCM workflow at large, making space for enhanced patient experiences.

Better Self-Pay Revenue

Patient information is electronically linked to the healthcare database, resulting in a rise in self-pay revenue. It overall streamlines the payment process for self-paying customers by assisting patients with unknown coverage and submitting their claims after cross-checking eligibility and coverage – all online.

Value of Eligibility Verification in RCM and its Impact on Patient Payments

Checking patient eligibility before appointments significantly impacts how quickly healthcare practices receive full payment for their services. By confirming insurance coverage in advance, practices can provide patients with estimates of their financial responsibility. This approach increases the likelihood of patients arriving prepared to settle their bills or establish payment plans.
Patients may not always have accurate information about their insurance coverage. The complexities and frequent changes in insurance details can lead to misunderstandings. Patients might be unaware of changes in their deductibles or other factors affecting out-of-pocket expenses. Promptly informing patients allows them to plan for additional costs or collaborate with the practice to set up a manageable payment schedule. Most patients prefer timely bill payments, and verifying patient eligibility helps practices assist patients in avoiding unexpected large bills.
Conducting eligibility verification ahead of time also protects practices from situations where insurance coverage has lapsed, or policies do not cover specific services. Such preventive measures ensure that practices can navigate potential payment issues with a clearer understanding of the patient’s coverage status.

Final Word

The eligibility verification process necessitates the involvement of experts with apt expertise and knowledge of the entire process. However, healthcare practices must focus on patient care and cannot compromise on this – for anything else. Still, no one can deny the value of eligibility verification in RCM. Thus, outsourcing your healthcare practice’s RCM process takes a load off of healthcare practices and gives them a clearer vision of their finances.

Frequently Asked Questions

The most common reason for denied claims is incorrect information. Be it by accident or intentionally, coding and billing errors are the most common reasons for claims denials due to incomplete, missing, or incorrect information.

Your billers can forward an appeal letter to the insurance provider stating why you believe the claim denial is wrong, thus, requesting the insurance company to reverse the denial.

It is a strategic process that aims to resolve and unmask problems that lead to claim denials.