Smooth claims processing is essential for insurance companies and policyholders in the complex insurance industry. Insurance eligibility verification is a crucial component that establishes the framework for a streamlined claims process. This essential process entails verifying the correctness and authenticity of policyholder information, coverage specifics, and other crucial data to evaluate if a claim is legitimate and should be processed.

Insurance eligibility verification is the foundation for effective claim processing and helps speed up valid claims while preventing fraud, giving policyholders peace of mind and financial security. Let’s explore more about it in this article.

What is Insurance Eligibility Verification?

Most people admitted to the hospital have insurance to cover their treatment costs. But hospitals and insurance companies do not just approve the amount; they have a process to follow known as insurance eligibility verification.

In this verification, the service provider checks for the insured person’s coverage status, eligibility status, and whether the insurance is active. These days, hospitals opt for insurance eligibility verification services to know the insurance details of their patients. It helps the hospital to inform the patient in advance if their insurance will cover the treatment cost or not.

What is the Insurance Eligibility Verification Process?

To check whether the patient is eligible for insurance, below are the steps that an insurance verification company has to follow:

1.   Patient’s Scheduling

The first thing the insurance verification company checks is the patient’s schedule. It can be done through an automated scheduling system that informs you about the appointment and other details.

2.   Enrollment Details

For a patient to get the claim and a healthcare provider to know the details, patient details should be adequately added to the system. These details must include name, address, date of birth, phone number, email address, etc. In addition, it should also have details related to allergies, medical history, and diagnosis reports.

Besides patient details, the enrollment form should also have an emergency contact number, doctor details, and the insurance provider’s details.

3.   Eligibility Check

A healthcare system must take care of its revenue cycle, or RCM process; an eligibility check is an important step. If the eligibility check is done properly, there will be fewer chances of claim denials. An eligibility check helps to avoid billing errors, delayed payments, and non-payment concerns.

Therefore, such checks should happen regularly, and the insured person should be made aware of their eligibility. For instance, if someone has to go for dental treatment and there has been a change in their marital status in the past few days or months, it can impact their coverage and claim.

Now, if the healthcare provider uses dental insurance verification services to get the eligibility check before scheduling the appointment, they can inform the patient about changes in their claim process.

4.   Pre-Approval

Eligibility checks further lead to approval or denial of patients’ treatment or medication costs, which is important for RCM. If the insurance company denies the case, the healthcare provider waits until they approve it, or they contact the providers to get it approved before starting the treatment.

5.   Meeting with Patient

Before the procedure begins, every patient detail should be collected and updated. It could include personal details, contact details, and health records. If any information is unavailable or incorrect, it should be updated ASAP.

6.   Updating Billing System

Unless the patient information is updated in the medical billing system or software, it will not be eligible for the claim. So, every piece of information must be updated, including the insurance coverage details. The healthcare provider can use advanced verification software to check the patient’s details and verify eligibility on every visit to avoid claim denials.

Rewinding the Insurance Eligibility Verification

The significance of confirming insurance eligibility cannot be overemphasized in the complex world of insurance. Insurance carriers can lay a solid foundation for efficient claims processing by carefully validating policyholder information, coverage specifics, and claim validity.

In addition to safeguarding insurance firms against fraudulent activity, this crucial step ensures eligible policyholders receive the benefits they are entitled to immediately. The road toward a smooth claims experience becomes a reality with the insurance eligibility verification process in place, representing the industry’s unwavering commitment to upholding the promise of protection and care.