27th July, 2023
Learning how to check insurance eligibility is one of the main crucial steps for healthcare providers seeking to significantly reduce their medical claims rejection rate.
Every healthcare provider must verify if a patient is truly registered with a particular insurance company, what insurance plan the patient is on, what benefits the patient can enjoy based on that plan, and if a particular service the patient is requesting is among those benefits.
When this is not done accurately, insurance companies will reject the medical claims prepared, resulting in a potential loss of revenue for the provider.
According to The Change Healthcare 2020 Revenue Cycle Denials Index published by American College of Healthcare Executives, 26.6% of medical claim denials occur because of registration/eligibility, and another 11.6% because of pre-authorisation issues.
Therefore, paying closer attention to insurance eligibility checks can help healthcare providers claim more earned revenue and improve their financial situation.
In this article, we will consider how to check insurance eligibility by highlighting four common ways healthcare providers do it, as well as introduce a better and more efficient way using new technology.
We will cover:
[Do you want to improve your insurance eligibility verification process and improve cash flow? Use KLAIM’s insurance eligibility verification software to automate checks, making the process more efficient and accurate.]
During the process of registering new patients, healthcare providers are required to collect key information about the patient. For patients who will rely on insurance to pay their medical bills, providers will also have to collect information relevant to their insurance plans. These include:
Once this information has been collected, the first part of the insurance eligibility verification will occur: whether the patient truly has the requested medical plan with a certain insurer.
When the patient schedules an appointment or visits the hospital (without appointment), the second part of the insurance eligibility verification will occur: whether the patient’s plan qualifies them for the particular medical service or benefit requested.
This is known as verification of coverage or verification of benefits.
Why is this important?
The insurer will refuse to pay if the hospital goes on to provide the service without confirming if the patient’s insurance plan covers it. Insurance plans have limits and patients must not go outside them.
Following that, there is a third part of medical insurance verification: pre-authorisation or pre-certification. In addition to verifying if a plan covers a service or benefit, there are certain services or benefits that require the healthcare provider to specifically seek permission from the insurer before proceeding with them.
In essence, while these services are part of the benefits of the plan, the insurer still has to decide whether they are medically necessary in this particular instance. Only after the provider has received authorisation can they proceed with the service or benefit.
These last two forms of medical insurance verification will require the provider to highlight the specific benefits in view using standard medical codes like the ICD-13, CPT, and the HCPCS.
It bears repeating that all these three stages of medical insurance verification are crucial if a provider wants to reduce medical claims denials and increase cash flow.
Before learning how to check insurance eligibility in the most efficient way, let’s consider the four common ways that healthcare providers currently follow.
The phone number of the payer (insurer, insurance company) is one of the information providers collect from patients at the registration phase. In some cases, this may not be required and the RCM staff can find the phone number on their own (in most cases, they already have it).
One of the popular methods many have learnt to verify insurance eligibility is to place a call to the insurance company of interest. All insurance companies have a telephone number through which providers can reach them.
However, as with most companies, these calls are answered by an interactive voice response. Again, like most companies, getting a human at the other end of the call can be time consuming.
Of course, the time it takes to connect with a human (and for the human to do the verification) may be unimportant during the first stage of verification: checking if the patient truly has an insurance plan with the insurer (provided the patient is not keen on receiving any service on the same day they registered).
However, when it comes to verification of benefits and identifying where precertification is necessary, this delay can cause a drag that can lead to long patient wait time, frustration, and patient dissatisfaction.
Similarly, there is always a risk of miscommunication, especially with medical codes.
A misheard letter or number can change everything. This can lead the insurer staff to say “yes” to something they should have said “no” to. This miscommunication can still lead to rejection of medical claims down the line.
To do away with the problem of miscommunication and delay in speaking to a human over the phone, some insurers have now provided dedicated platforms on their websites where the RCM staff of providers can verify eligibility.
With the basic information highlighted in the first section, RCM staff can check through insurers websites for all the three stages of insurance eligibility verification. The websites should show if the patient has a plan, if the benefit in view is part of the plan, and if it requires precertification.
While this is an improvement on verifying through the telephone, there are also weaknesses.
First, many of these websites are often outdated and new information about benefits and pre-authorisation conditions are absent. If providers rely on outdated information to make a decision, the insurer will reject the prepared medical claims.
Second, though there is no extra time waiting for a human to pick up the phone, the process of verifying eligibility for each patient one-by-one can be stressful and time consuming, especially for hospitals with considerable patient traffic.
In the end, long patient wait-time and patient dissatisfaction may persist.
Some providers attempt to deal with the problem of outdated website portals by using the insurer’s question form to create a request.
However, this is hardly an improvement.
First, because of spam, many companies don’t pay much attention to submissions through question forms on their websites any more. Therefore, there is a big chance that forms submitted for verifying eligibility may be lost.
Even when it’s not lost, the response time may be worse than waiting for an interactive voice response to transfer a call to a human. Anyone who has waited to get a response to an email from a company knows how some of them may deliver for upwards of 48 hours.
Consequently, this is also not an efficient method even if it might result in more accurate results. The problem of patient wait-time worsens with this method.
Sending a direct mail (rather than using a question form) is not an improvement as well.
Email can go straight to the spam box, it might get lost in the horde of emails, and even when it is not, response times may also take longer than with a telephone call.
There are clearing houses that allow you to check insurance eligibility with multiple insurance companies from a single portal.
While they can be more efficient than visiting multiple websites in a day, they don’t solve the problems we have already identified.
Like the individual websites of payers, they are also often outdated. Relying on them can be risky, leading to loss of revenue down the line.
Also, while most of them can help you perform the first part of eligibility verification – whether a patient has a plan with an insurer – they don’t have the capacity for the verification of benefits or the verification of the conditions needed for pre-certification.
Similarly, only a few of them allow you to verify medical insurance eligibility in batches. Many of them still require verifying eligibility for each patient one-by-one.
In essence, the problems of outdated information and added time persist.
As part of its goal of improving revenue cycle management in healthcare – through its RCM 2.0 platform – KLAIM has built insurance eligibility verification software that uses robotic process automation (RPA) to make the process more efficient and accurate.
How does this software work?
Like the insurance verification eligibility portals provided by some clearing houses, KLAIM’s health insurance verification software offers a single platform that aggregates info for all major payers.
In addition, KLAIM’s software also allows:
Through these features, providers can improve patient satisfaction (reducing wait time, avoidance of unnecessary trips, etc.), reduce manpower costs (the software uses bots), improve operational efficiency (cancel unnecessary appointments, less crowded waiting rooms), and prevent avoidable medical claims (removing a significant cause of denial: eligibility/pre-authorisation).
The structured and intuitive user interface (UI) of this software also makes it attractive and easy-to-use for providers.
This insurance eligibility verification software is part of a broader next-generation solution that we call RCM 2.0, which also includes a claims rules engine, RCM analytics, and advanced financing.
[Do you want to reduce your medical claims by efficiently and accurately verifying insurance eligibility? Use KLAIM’s insurance eligibility verification software as part of a RCM 2.0 solution to improve your hospital’s financial health.]