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Eligibility Verification

Eligibility verification is primarily an insurance business concern and by definition simply means the process to verify patient’s insurance policy eligibility and coverage. This is one of the most complicated processes because it is the very eligibility confirmation that decides on the payout amounts, therefore, the entire operations of the insurance companies. The smallest billing error or problems in collections can have consequences not only for the insurance companies but also for the patients. Even from solely a business’s perspective, even if the patients are at the losing end, it could lead to law suits, legal fines and penalties and eventually financial and operational losses for the insurance companies. The cost of losing customers due to dissatisfaction is equally harmful. The human factor of suffering and delayed insurance payments is in itself a huge enough loss that is necessary to be avoided.

Steps in Eligibility Verification

Receiving patient schedule: This is the first step where you get the demographical details of the patient, from a designated authority such as a hospital or clinic. Patients can provide the details themselves too if their insurance agreement states so.

 

Verifying patient information: The services include in this part of the process are verification of payable benefits, deductibles, type of coverage and policy, patient policy status, effective dates, and any exclusions. Primary and secondary payers are also to be identified along with updating on patient accounts and completing paperwork in communication with patients.

 

Pre-certification process: This is the most complicated step of the whole process since it requires a lot of documentation, sheets, forms, and also a whole myriad of processes. After the pre-certification number is obtained that are needed for a visit, procedure or treatment, the appropriate criteria sheets need to be filled for which insurance companies are needed to be contacted. Once those forms are completed then the specialists will follow up for the authorization and coordinate with the client.

Potential Results of Improper Eligibility Verification

If there is a glitch in the process of eligibility verification there are not only denied claims and delayed payments for the patients, but sometimes ineligibility based rejections can end up in completely depriving the patients. There can also be the need for resubmitting claims and patient dissatisfaction that can cause troubles for the insurance companies as much as the patients.

 

The problems are not limited to the ending part of the process. The management of staff workflow, record keeping, and the importance of maintaining security are all sensitive areas and any trouble in their smooth flow can lead to enormous issues, in financial terms, time costs, and can also lead to reputation loss for the business.

Why Eligibility Verification is important?

As the healthcare industry continues to go through innovation, not just in the existing processes, but also in the portfolio of services being offered, the responsibilities and liabilities are also changing. And along with all of that the costs are also rising as is the competition. The responsibility of providing the exemplary error free service is not only important for the companies’ image but also to keep and improve the number of customers. Patients prefer and stay with insurance companies that not only provide overall better service but also maintain engagement with patients as well as the healthcare institutions.

 

To ensure that proper services are being provided, there are a number of things that are needed to be taken into consideration including optimizing revenues, improving patient experiences, streamlining payment collection processes, engagements with patients at several points of service, ensuring smooth enrollment services, and overcome patient access challenges.

How Intersoft BPO can help you?

Considering the significance of the eligibility verification performance it is only logical that healthcare and insurance companies need to arrange for appropriate measures to ensure proper and quality service. The steps involved in the entire process span several departments within a business looking over verifying eligibility requests, receive payers’ responses, avoid billing costs from insurance verification errors, determine financial responsibility, and eventually handle operations to work towards revenue enhancement and cost savings.

 

All these tasks require qualified professionals and lots of money for the appropriate software and working space. This means that any business dealing with all the processes mentioned henceforth will have to provide for working space and the utilities expenses. This is where Intersoft BPO can aide you massively. We not only have experienced professionals on board to make sure communication with your customers is smooth and there is no hiccup in the payment of dues to patients either. Side by side we also have the state of the art technology that removes the possibility of any error in eligibility verification process and thereby avoiding any legal penalties as well as patient grievances.