How Does Insurance Eligibility Verifications and Pre-Authorizations Work?

Most claim denials are due to the lack of verifying benefit information prior to services being provided. Insurance verification process is crucial for all hospital encounters, whether inpatient, outpatient or ambulatory care. It will ensure that the hospital receives payment for services rendered and will help determine the patient’s share of the hospital’s charges referred to as the patient’s responsibility. Eligibility verification is the process of checking a patient’s active coverage with the insurance company and verifying the authenticity of his or her claims. In order to avoid claim rejection, the verification process must be done before the patient is admitted into a hospital, see a physician or gets services by a medical professional.

Coverage and eligibility benefits should be verified for all new patients and hospital admissions. Coverage and benefits will also be verified for any patient who indicates a change to their coverage and for all high dollar procedures. Pre-authorization is required for many non-emergency medical procedures and services.

Caught between practice administration and patient care, many physicians find it difficult to complete such important tasks on time. Outsource Strategies International (OSI) can assist physicians and healthcare practices with their insurance eligibility verifications and pre-authorizations process reducing coverage errors, minimizing rejections and denials and improving bad debt write-off scores.

Knowledgeable in each and every aspect of health insurance, healthcare terminologies and medical/surgical techniques, they work with payers as well as patients to verify eligibility and provide authorizations for services or procedures to be provided.

Insurance Eligibility Verification

– Step by Step Process

  • Receiving patient demographic information from referral sources such as hospital or clinic or from the patient directly.
  • Verifying patient information with the carrier. This service includes verification of:
    • payable benefits
    • co-pays
    • co-insurances
    • deductibles
    • patient policy status
    • effective date
    • type of plan and coverage details
    • plan exclusions
    • specific coverage
    • claims mailing address
    • referrals and pre-authorizations
    • life time maximum
  • Verifying patients’ coverage on all primary and secondary payers
  • Updating patient accounts
  • Communicating with patients and completing paperwork

Precertification Process

  • Obtaining pre-certification number from the when needed for a procedure, visit or other treatments
  • Completing appropriate criteria sheets and forms
  • Contacting the insurance companies on the physician’s behalf to obtain approval for your authorization request
  • Once the forms are filed either online or via a web portal, then the specialist will follow up until authorization is received.
  • If any further documents are necessary we will coordinate that with our client.

Specialists can also communicate with companies for appeals, missing information and other details to ensure accurate insurance billing. Once the verification process is over, the authorization is obtained from insurance companies via telephone call, facsimile or online program.

Contact us at 1-800-670-2809 and speak to our Solutions Manager to find out more on how we can help.

An infographic presentation of the insurance verification process is given here.