Tired of Claim Denials? Here’s a Modern Guide for Eligibility and Benefits Verification!

Providing ultimate patient care feels rewarding and helps you connect with clients positively; however, claim denials can be a nightmare. Imagine spending weeks treating a patient, only to realize their insurance won’t cover the services, resulting in claim denials.

This is where eligibility and benefits verification come into play. It ensures that the patient has active insurance coverage and benefits before receiving therapy services. This is crucial to ensure accurate billing, reduce claim denials, and enhance user experience. 

Additionally, verifying eligibility accurately can help therapy practices remain financially stable while delivering top-notch patient satisfaction. In this blog, we will explore the importance of eligibility verification, the steps involved, the benefits, the challenges, and how automation with TherapyPM can expedite the process. 

Importance of Eligibility & Benefits Verification

The success of a therapy practice lies in accuracy and transparency in providing healthcare services. Often, therapists undergo painful claim denials and rework, which can result from billing errors, even if minor. Especially with manual paperwork, it can be harder to juggle all the information from therapists. 

Eligibility and benefits verification is the process by which insurance companies verify patients’ insurance eligibility to determine whether they can receive the therapy services. This is a crucial process for healthcare providers, patients, and insurance companies as a whole. 

Steps in the Eligibility and Benefits Verification Process

The insurance eligibility verification process comes with a series of steps to ensure accurate billing and enable patients to understand their financial responsibility. BlueCross BlueShield of Texas suggests checking eligibility and benefits before the appointment, and whether it includes all the required information and documents. 

Here are some steps on how to verify the insurance eligibility and benefits:

1. Collect Patient Information:

Collect the patients’ demographic and insurance details – full name, date of birth, insurance policy number, group number, and any relevant information. 

2. Verify Patient Identity:

Confirm the patients’ identity by checking their photo ID and insurance card. 

3. Contact the Insurance Provider:

Use online portals, automated verification lines, or contact the insurance company directly to confirm the patients’ coverage and benefits. 

4. Confirm Coverage Details:

Confirm which plan the patient is using, such as  HMO, PPO, etc. Also, review the covered services, copays, deductibles, coinsurance, and any plan exclusions. 

5. Check for Referrals and Authorizations:

Verify if the patient requires any referrals or pre-authorizations for specific treatments or therapy services. 

6. Document Verification Results:

Record the verified information into the patient’s record – policy details, coverage, and any required authorizations. Additionally, maintain a detailed record of the eligibility verification process for future reference and claim submission. 

7. Communicate with the Patient:

Update the patient about the status of their insurance coverage, benefits, and any out-of-pocket costs required to be paid. 

8. Re-verify as Required: 

Regularly re-verify the patient’s insurance information, especially when it comes to recurring services or monthly visits, to ensure accuracy always. 

Note: If you are catering to a Medicare patient, you can check their eligibility requirements here. 

Benefits of Accurate Eligibility Verification

Accurate eligibility verification is essential for therapy practices to reduce claim denials, enhance patient satisfaction, and ensure revenue cycle management is efficient. Studies suggest that the insurance verification rate benchmark is 90%; therefore, practices must aim to verify patients’ coverage up to this mark before any appointment/service.

Here are some of the benefits of accurate eligibility verification for your therapy practice and clients: 

1. Reduction in Claim Denials:

Insurance eligibility verification ensures claims are submitted correctly on the first attempt. This saves time and cost, leading to faster reimbursements and improved cash flow for healthcare providers.   

2. Improved Patient Satisfaction:

Providers can explain to patients about their insurance coverage benefits and any out-of-pocket costs. This can foster patient trust, loyalty, and satisfaction.

3. Efficient Revenue Cycle Management:

Accurate eligibility verification streamlines the billing process, reduces delays, and enhances the overall efficiency of the revenue cycle and financial performance.

4. Decreased Administrative Burden:

Automating and verifying eligibility accurately can reduce manual checks and follow-ups, reducing administrative burden and allowing more time for patient care.p-

5. Enhanced Compliance:

Accuracy in eligibility verification enables therapists to comply with regulatory requirements and avoid potential legal issues with billing and insurance claims. 

6. Cost Savings: 

Eligibility verification helps reduce errors and the need for resubmission, significantly saving costs.  

7. Quality Patient Care:

Staying up-to-date with the eligibility benefits can enable providers to focus more on patient care and less on admin tasks for better outcomes. 

8. Reduction in Payment Delays: 

Accurate insurance verification can reduce the time taken to submit a claim versus receiving the payment, hence improving the practice’s financial health. 

Challenges in Insurance Eligibility Verification

While verifying the required eligibility benefits for your patients, it is not uncommon to face challenges. Even small errors can result in bigger problems. Here are some of the common challenges that therapists face during insurance eligibility verification: 

1. Inaccurate or Incomplete Patient Information:

Patients might present outdated insurance cards, enter wrong policy numbers, or forget to mention secondary coverage. Even small data entry errors by staff can result in claim denials and reduce accuracy. 

2. Complex Insurance Policies:

Insurance plans vary in terms of coverage, exclusions, and billing rules; therefore, staff feel pressured to stay constantly updated and well-trained. Even a tiny misunderstanding of the policy’s print can delay reimbursements or cause billing errors, even when covered. 

3. Manual and Time-Consuming Processes:

The majority of the therapy providers still rely on manual methods, such as phone calls or paper forms for insurance verification. Although comforting, it slows down operations, increases human errors, and reduces efficiency, especially in high-volume practices. 

4. Frequent Insurance Changes:

Patients often change insurance plans due to life events, job transitions, or open enrollment periods, and it should be recorded and verified in real time. If providers ignore this, they may unknowingly deliver services to patients without active coverage, leading to denied claims and unexpected out-of-pocket costs. 

5. High Volume of Insurance Payers:

The healthcare system consists of many insurance companies, and they come with their verification protocols and requirements. Any lack of standardization can make it difficult for providers to maintain consistency and accuracy, especially with multiple payers for a single patient.

6. Claim Denials and Revenue Loss:

Failed eligibility checks are a leading cause of claim denials and impact the providers’ revenue cycle. Many denied claims are never resubmitted, resulting in lost income and increased workload for billing staff.