Understanding Eligibility and Benefits Verification And Their Importance

 

Eligibility and Benefits verification is one of the most needed steps for effective RCM. Missing this is like constructing a building with a weak foundation. You cannot expect the building to thrive.

Eligibility and Benefits verification is the process of verifying information like coverage, deductibles, copayments, and co-insurance before filing a claim. 

A 2020 report released by the Centers for Medicare and Medicaid Services (CMS) states that claim denial rates ranged between 1% and 80% in the country! An average of 18% of in-network claims got denied that year. This could be a considerable number, given the high cost of healthcare. 

Claims need to be built based on the eligibility of the patient. A haphazardly created claim with services the patient was not eligible for in the first place would lead to quick and hard denials from the payer's (insurance provider's) end.  

Inefficient Eligibility and Benefits verification processes cause the following problems. 

· High denials rate

· Delayed payments and extended AR cycle

· Reduced overall collections

· Increased expenses for appeals

· Increased labor time and effort

 When does one start checking eligibility? 

Ideally, experts suggest checking for eligibility at least 48 hours before a patient's appointment. This     way, if there are questions or additional details needed from the patient's end, this can be sorted out well in advance.  

Eligibility coverage information should at least include the below basic details.

1. Patient name and Subscriber name

2. Relationship to the primary subscriber

3. Patient date of birth, age, gender, member number

4. Payer details like group name, number, and type of coverage

Collecting additional information is always encouraged. 

 If you have an in-house billing and coding team, make sure they have the capacity to handle Eligibility and Benefits verification right. Overworked teams often leave this to chance and end up causing high denials rate. High denials are added stress to the team, and this, in turn, affects their efficiency. 

This could become a vicious circle when left unchecked.

 If you are working with a third-party RCM service provider, then talk to them and understand their Eligibility and Benefits verification process. They should have the tools and expertise to handle verification right. Manual verification is a cumbersome process, and human errors cannot be avoided here.

 Deploying tools to automate this process makes it quicker and more efficient. A good Eligibility and Benefits verification tool should assist in the following ways.

· Handle verifications and prior authorizations wherever needed

· Verify patient demographics

· Verify primary and secondary payers' coverages and benefits

· Automate payer follow-ups

· Initiate appeals in case of denials

 Conclusion

Once you master Eligibility and Benefits verification and get the process right, the next steps of RCM get easier and more streamlined. Audit your existing verification processes and find out how this can be improved. Work with the right RCM service providers to ensure they help perfect eligibility verification and prevent non-eligibility denials.