Jackie Butcher Dec 7, 2022 2:01:52 PM 4 min read

The Importance of Patient Eligibility Verification

A healthy practice starts with effective revenue cycle management (RCM), and effective RCM starts at the very beginning – with verifying patient eligibility. Checking eligibility entails confirming the patient’s insurance information, including their coverage, copayments, and deductibles. Without this important step, claim denials can increase and the practice’s revenue can suffer.

Below are a few helpful reminders when checking patient eligibility.

1. Run the task overnight – In an ideal world, patient eligibility verification should be set up as a task in your PM system to run overnight. That way, when your staff arrives in the morning, they can review and identify where the insurance issues are going to be, allowing them to address them at time of service. If you are unable to run the task overnight, it is important that your front office team verifies eligibility when checking in your patients.

2. Clean up your process – When checking in your patients, the process should be as clean as possible to ensure that the claim gets to the payer without issues and paid in a timely manner. If a claim is submitted and the patient is not eligible on the plan listed, your team must research to find out what their insurance is – or if they even had insurance at the time of the visit. It can be helpful to first check the patient record to see if there is an updated card that was simply not added to the claim. If that’s not the case, then you should move on to Medicare if age appropriate and then Medicaid. If the patient is not eligible for either of those, you should then send the bill to the patient, in the hope that they call you back with their insurance information.

3. Be mindful of timing – When a patient either does not call back or waits too long, it often becomes too late to file the claim with the payer. Insurance companies have timely filing limits that vary, but generally range from 90 days to one year. Most offices will not bill the insurance once the claim is late because it will be denied, as it is the provider’s responsibility to file the claim in a timely manner. At this point, your practice must inform the patient that the balance is their responsibility to pay, as they did not provide insurance at the time of service and did not respond to received statements.

Eligibility verification only becomes more difficult after a patient leaves the practice, so it is critical to gather the information you need at the time of their visit. With an effective check-in and verification process, you can increase your chances of having claims billed and paid in a timely manner.