Enable Accurate Collections with Insurance Eligibility Verification

December 8, 2022

This guide will walk you through how eligibility verification can help speed up the medical billing workflow and reimbursements. We will also discuss the main reasons that result in claim denials, what steps the eligibility verification process should follow and what physicians should do. Besides, we will explain the benefits of getting an outsourced medical billing services to ensure a healthy revenue cycle.

What is Insurance Eligibility Verification?

Insurance verification is systematically getting in touch with the insurer to see whether the patient is eligible and whether their health insurance covers the necessary procedures.

The insurance verification procedure, which is the initial step in the medical billing process, covers plan exclusion, policy status, deductibles, and other items affecting cost and coverage. It is completed prior to patients being admitted to the hospital.

Skipping the insurance verification process could result in a patient being hit with unforeseen high medical costs or your practice receiving unpaid or denied health insurance claims from the insurance companies.

A recent study found that the procedure of verifying insurance cost healthcare providers 30% of their annual income on average. Verifying insurance claims before providing service can help unlock value and stop income leaks, ensuring a healthier revenue cycle.

Factors in the Insurance Eligibility Verification Process that Cause Claim Denials

The following are the leading causes of claim denials in the process of determining insurance eligibility:

  • No Patient Information
  • Expired Policies
  • Claim Billing Errors
  • Coverage Effective
  • Duplicate Data
  • Termination Date

These invariably lead to claim denials, non-payments, claim rework, delayed payments, and increased patient and provider expenses. As a result, the revenue decreases, while patients become dissatisfied with the medical practice. Additionally, in the age of YELP and Google reviews, it can also impact the provider's reputation.

Overview of the Claim Verification Process

Verifying insurance can improve the practice of medicine and make it safer, more rewarding, and more pleasant for your business. It can help address all of the following concerns effectively, ultimately making your healthcare facility more profitable with a steady cashflow:

  • Is the rise in administrative expenses affecting your practice?
  • Are errors in insurance claims, claim denials, and unpaid patient treatment costs overwhelming your business?
  • Are you squandering valuable time filing insurance claims when you could be spending it caring for your patients?

What Should Physicians Do?

Healthcare providers may prevent setbacks by working with the appropriate outsourcing partner to aid and support the claim process and guarantee seamless revenue cycle management.  

The ideal partner would take care of the following activities:  

  • Establish Streamlined, Transparent Processes  
  • Give Knowledgeable Advice
  • Assure Consistent Cashflow
  • Cut Back on Staff Workloads
  • Be Economical
  • Recognize CMS Regulations and HIPAA Requirements

Checklist for Verifying Insurance Eligibility

Discussed below are some best practices for determining a patient's eligibility and benefits:

  1. The first step should always be to verify the status of the plan.
  1. Always inquire about any upcoming or recent insurance changes with the patient.
  1. Verify whether the patient has primary, secondary, or tertiary insurance. Besides, ensure the patient's Coordination of Benefits (COB) is regularly updated with each payer.
  1. Verify Medicare coverage for patients over 65.
  1. Recognize whether you require a referral or prior authorization for the particular medical procedure. Get the necessary referrals or authorizations and update the revenue cycle system if necessary.
  1. Verify the patient's insurance coverage for the surgery.
  1. Some plans define a cap on benefit limitations and restrictions on the number of visits and time frames during which medical services can be provided. The front desk must obtain these facts.
  1. Calling the insurance provider may be necessary for some services related to behavioral and mental health, drug abuse, and addiction. You must consult payer-specific guidelines if you are unaware of these criteria.
  1. Payments are the patient's obligation. Depending on the specifics of the coverage, collect payments for deductibles, copayments, and coinsurance. It might be tiring to pursue patient collections, and you have to make the required upfront payments.

Bonus Tip: Social determinants of health are advancing healthcare fairness and access and are becoming a crucial component of care delivery. For Meaningful Use reporting, details like race, gender, ethnicity, birthdate, preferred language, etc., are essential.

Benefits of Outsourcing Insurance Eligibility Verification

You can get assistance from a professional medical billing company to take care of insurance verification, coding, and medical billing. Their tailored medical billing services enable you to hire experts for less money and lighten the pressure on your revenue cycle team. Some advantages of outsourcing include the following:

  • Allow your personnel more time to work on the revenue cycle and other patient experience improvement tasks.
  • Accelerate the delivery of care
  • Reduces claim rejections and denials, resulting in speedy reimbursements
  • Cost savings achieved through labor rate arbitrage
  • Keeping policies and processes up to date

If you want to outsource your medical billing to the best medical billing company, look no further and schedule a demo with talkEHR.


This guide explored how insurance eligibility verification can help streamline medical billing and generate a steady cash flow. talkEHR’s medical billing services will provide you with complete revenue cycle support, reduce administrative burden, and increase your profitability by reducing the claim denial and rejection rate.