There are different ways for checking insurance eligibility of patients based on the process and procedure of your office and the insurance carrier. Patient eligibility is important for the income and productivity of a medical practice. The process involves important questions you should ask and verify with the insurance provider and the patient.
- Check whether the insurance identification card of a new or a returning patient is correct and updated. You may cross check the same with the insurance carrier.
- You can also verify insurance information by checking the insurance carrier’s website or by checking it with a representative directly. Certain clearing houses and practice management software can also assist you in ensuring eligibility.
- A primary care giver should confirm that the insurance is in effect when the patient gets the medical service and ascertain the amount the patient must pay (co-insurance / co-pay). In the case of a specialist, the medical practice must check whether the co-pay for a specialist visit is different from the co-pay for a primary care visit. The specialist must also verify whether the service requires a pre-authorization or a referral.
- A specialist or a primary care doctor must check if the insurer considers the practice as an out-of-network or in-network provider because the benefits are different in either case.
- Medical practices seeing Medicare patients must check with carrier before consultation because coverage with a Medicare Managed Care Plan is likely to confuse patients. It is also common for Medicare patients to say that they have Medicare while they might actually carry a Medicare ID card not knowing that they have enrolled in a Medicare Managed Care Plan. Irrespective of the plan, verify the insurance coverage when the patient is at your office to prevent delayed claim / payments due to incorrect information.
- For a new patient, verify insurance information when the appointment is made. This would give adequate time for the office staff to verify the information with the insurance carrier in advance. Also, let the patient know the amount they are expected to pay.
There are many factors that define the financial responsibility of a patient. Some of them are, whether or not the insurance provider is in the network, patient deductibles and the type of the provider.
To ensure all information is collected at the time of the patient visit, use a checklist that has:
- Patient NameDate of Birth
- Insurance Carrier
- SS Number
- Insurer Phone Number
- Address for Claim Submission
Basic Questions to be asked:
- Is provider referral necessary?
- Is authorization required?
- Are you in an out-of-network or in-network provider?
- What is the amount of patient deductible?
If you want to be more efficient use Electronic Medical Billing to save money and practice time.