Insurance eligibility verification is the foundation of the medical insurance billing cycle and it has the power to decide the fate of a claim. At times we don’t give adequate significance to doing insurance eligibility verification. We have an impression that certain claims don’t require insurance eligibility verification and we fail to foresee the consequences that we would have to face by not doing the verification. When it comes to business, big or small, a loss is a loss. The loss is to be borne by physicians or patients. Even the medical billing companies are at loss if there are delays and denials. To avoid this unpleasant situation, we need to adhere to a better and streamlined process flow which will be initiated by doing insurance eligibility verification irrespective of whether it is an ordinary health plan, PIP or workmen comp
Let me discuss about the major issues arising out of non verification of insurance which would lead to denials if not handled appropriately.
1) Verifying the effective date is essential to avoid denials due to expiry of insurance coverage
2) In certain cases, patient’s primary insurance gets expired and he/she uses the secondary insurance that doesn’t cover the ailment in which case the claim will be denied.
3) Patient would not have paid the premium and his/her insurance coverage would have expired. It is important for the physician to know this earlier in order to make out payment details from the patient.
4) To find the primary insurance carrier of a patient, it is essential to do insurance eligibility verification.
5) In case the patient is covered under multiple health plans, insurance eligibility verification is essential to avoid wrong billing for a different health plan.
6) At times patient would have changed his/her health plan but would have not informed about the change to the provider. Many complications might arise due to this and it is advisable to do insurance eligibility verification.
7) Certain insurance carriers accept the claim only if it is submitted in the name of a physician who is qualified for that service.
8) At times, when there is a mismatch in the information regarding the primary care physician, claims would be denied. Certain carriers are strict about this and it is essential to do insurance eligibility verification.
9) The possibilities of claim denial are more when the provider is not in par with the insurance company.
10) Deductibles, co-pays: It is inevitable to check if there are deductibles and co-pay for the patient in order to avoid any confusions with the payment
11) Diseases occurring due to pre-existing conditions like diabetic retinopathy and diabetic kidney disease are not covered by some insurance carriers
12) For certain services pre-authorization is essential from the insurance carriers and if not the claims would be denied
13) Insurance carriers set up visit limits to the insured and incase if the visit limit of the patient has exceeded, then it will not be covered under insurance plan.
14) Some lab services are not covered under certain health plans and the claims are likely to get denied if the lab tests are not done in a preferred lab. Physicians should know this in advance so that he/she can discuss this with patients and decide accordingly.
15) Certain insurance carriers don’t provide insurance coverage for routine checkups and it is necessary for the physician to know this in advance
16) At times the health plan possessed by a patient might not provide coverage for certain diseases and the claim would be denied. To avoid such denials, insurance eligibility verification is essential.
17) In case of workmen compensation, it is necessary to do insurance eligibility verification in order to know who the adjustor is.
18) In workmen compensation, knowing the compensable body part is essential in order to avoid uncertainty with the insurance coverage.
By doing effective insurance eligibility verification, healthcare organizations can avoid losses, delays and reworks. Insurance eligibility verification also saves valuable time by avoiding the unnecessary billing process for a claim which is sure to get denied due to issues with the insurance coverage.
Article By: Madhumitha Balasubramanian
scenario you are medical biller and are speaking with an insurance company regarding a denial of coverage for a paticular patient discuss the patient and the procedures provided with the insurance company,
post a scenario you are medical biller and are speaking with an insurance company regarding a denial of coverage for a particular patient discuss the patient and the procedures provided with the insurance company,