What is the most important step in the billing process?
Documentation? Coding? Claim Submission?
Without proper eligibility, your claim is dead before it ever started.
When talking about eligibility there are lots of terms that get mentioned around checks and patient eligibility – verification of benefits, coverage, pre-authorizations, eligibility or check for benefits, etc… These terms essentially mean the same thing. Most offices are looking for either benefit verification or eligibility of benefits.
Eligibility is more simplified. This describes if the patient is eligible and are they covered by that payer and plan. Presentation of an insurance ID card is not a guarantee of eligibility. The provider is responsible for verifying a member’s current enrollment status before providing care.
Verification of Benefits allows you to go deeper and find out exactly what is covered by the payer for that patient. This allows you to determine a specific line of benefit or service that you believe is going to be performed in the practice or clinic. Benefits can vary. Before rendering service, verify that the service is a covered benefit under the member’s plan.
We will examine these two different “checks” and the ways that we can use this information. Before we dive in, there are some basics to cover…
The Basics of Insurance Eligibility Checks
We won’t cover Medicare here. For this article, we will speak to commercial payers. There are some limitations around non-covered services and advanced beneficiary notices (ABN) which we will cover in a separate article.
Benefit verification may not be as detailed as needed and will still require that the insurance companies review the diagnosis and all the considerations included on your claim to confirm that benefits are payable.
To perform an eligibility check or verification of benefits, you will need some minimum information.
Date of Birth
Insurance Member ID or Member Subscriber Number
If you need to verify a specific service line or procedure, you’ll need more details. For a specific service, you may also need that procedure code, ICD-10, CPT, or HCPCS codes.
One of the simplest methods is to go directly to payer portals and sites. Insurance companies like Blue Cross Blue Shield, Aetna, or United Healthcare allow providers to enter information directly into their portal. Look for “Member Services” or “Provider Portal” to find the payer’s eligibility and benefits tools.
To access either the payer website you will need to enroll with a plan and register with this tool. Be aware that oftentimes the registration with direct to payer can take time to get up and running.
Through a Clearinghouse
If your practice accepts many different insurance plans and providers you may want to explore a more centralized option. Tools like Availity and Ability Network make it possible to check a larger number of payers in one portal. This allows providers to get information from five, six, or even ten payers in one place rather than operating in ten different portals or websites.
If you use a clearinghouse to submit your claims to an insurance company, it’s likely your clearinghouse has some sort of eligibility verification tool. This process may not go deep enough to give you full detailed benefits or service level benefits, but you will get at least the basics of what you need for eligibility checking.
Some clearinghouses can provide a batch process to run many eligibility checks at once. For example, your practice might check the insurance eligibility of all patients on the schedule for this week. This process typically takes some time to complete the run or report, so don’t expect an immediate response.
Check eligibility through your software
PatientStudio has integrated eligibility checks inside your software! Your practice management system can check a patient’s eligibility before their visit or generate an eligibility check immediately if you need a quick response. PatientStudio can provide a detailed verification of eligibility so you can provide coverage and copay information to your patients immediately.
Now you can check patient eligibility in the same place you schedule patients and document clinical notes.
Because PatientStudio online intake forms will capture insurance information you won’t even need to enter data to perform an insurance eligibility check. Simply click the button and get an instant response. You can automatically check 24 hours in advance of a patient’s appointment or at the time of scheduling to let the patient know if the insurance information is eligible or if it needs to be updated.
PatientStudio allows you to perform real-time eligibility checking. If you do not have the insurance information in advance, you can perform an eligibility check on the spot.
Call the Payer
If you’re more old school, you can call the payer directly. Most often you will get the payer’s interactive voice response system (IVR). This is the automated system when you call an insurance company. The IVR will go through questions to confirm information to provide the basics of that patient’s eligibility.
It is possible to speak with a human at an insurance company. However, this takes an enormous amount of time if you consider hold times are incredibly long. Most insurance companies aren’t putting many resources here, so expect hold time to continue to increase.
It is extremely important to notify your patient this is just an estimate this is not a guarantee of benefits (The same disclaimer that the insurance companies give to providers). Make sure to let your patient know that you are required to submit a claim, allow it to go through processing to know the exact patient responsibilities, and confirm benefits are payable.
If you want to learn more about PatientStudio and real-time eligibility checks, schedule a no-obligation demo now.