Importance of Efficient Insurance Verification

Insurance verification is a very time-consuming process but it is most important for hospitals and physician practices since it is the first step towards ensuring reimbursement. It is vital that the practice understands the coverage for specific procedures offered by the patient’s insurance plan before the non-emergency service is rendered. Or else the risk of delayed payments, claims resubmission, and nonpayment would loom large – certainly not what a successful practice wants.

Reducing the Burden of Insurance Verification

But there’s no taking away the fact that it consumes a good deal of time and resources for your staff. That’s where EDI (electronic data interchange) can help. It helps your practice submit eligibility requests faster and receive appropriate payer responses accurately. It also enables you to detect the primary care provider as well as other medical coverage. You can reduce the chances of claims rejection and obviously the billing costs arising from errors in verification. It becomes easier to determine the financial responsibility of a patient at the point of care thanks to the electronic eligibility response. And here’s another advantage – your staff can focus more on providing care to patients and the other revenue churning activities.

Understanding Claim Denials

It is important to remember that most of the insurance denials are caused due to lack of proper insurance benefit verification before care is provided.

Here is one of the most common denials:

• Requires Prior Authorization

This is one of the major reasons for claim denial since some of the services or procedures require authorization before they are performed. These denials normally happen in hospital settings. But the responsibility for obtaining prior authorization rests with the physicians’ office since if that isn’t set right, the hospital loses revenue.

Other common denials are:

• Coverage Terminated

This brings to light the importance of the physician’s office verifying the insurance eligibility of the patient’s insurance each time a service is provided. This is because insurance details can change, even if you’re dealing with regular patients.

• Services Non-covered

There can be differences between individual policies and insurance companies on medical services that are covered. If there are procedures that are not covered, the patient must be made aware of that rather than being hit with the bill unexpectedly. Letting the patient know that in advance can help him/her make the decision whether to go ahead, or be prepared to bear the cost.

• Maximum Benefit Has Been Met

This usually happens in treatments such as chiropractic, physical therapy, behavioral health, etc which require repeated hospital or physician office visits. Insurance plans normally fix a limit to the number of visits allowed in a particular period.

An efficient verification and pre-authorization procedure is essential for any hospital or physician practice. It may be time-consuming and exhaustive, which is why insurance verification service providers can ensure efficiency in this process while your staff can focus on providing quality care to your patients.

OSI provides RCM services for dental and medical practices of all sizes and specialties. Services include billing, insurance verifications, prior authorizations, coding, A/R management and more.