Federal Government to Tighten Health Insurance Eligibility Verification

by | Last updated Nov 15, 2023 | Published on Jun 20, 2016 | Insurance Verification and Authorizations

Tighten Insurance Eligibility verification
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Recent reports indicate that the federal government is planning to perform additional insurance eligibility verification for people who enroll outside of the enrollment period. According to a Wall Street Journal report published earlier this year, the government’s decision was prompted by insurers’ concerns that people are abusing the rule that allows them to sign up through HealthCare.gov outside the official sign-up periods if they meet certain criteria. Payers have pointed out that many people are waiting until they get sick to buy insurance, and this is driving up insurers’ costs and thereby, insurance premiums.

A person is eligible to use the health insurance market place if he/she:

  • Lives in the United States
  • Is a U.S. citizen or national (or be lawfully present)
  • Cannot be incarcerated

The special enrollment periods allow individuals to get coverage in a special circumstance such as if they lose their existing coverage, change place of residence, or have a change in their household like getting married or having a baby.

The WSJ report states that CMS will now require consumers who enroll after the official enrollment period ends to submit documentation confirming their eligibility in the 38 states that use the federal health insurance exchange website. They must also be ready to answer any queries that arise after their documentation is reviewed by the authorities. Failing to respond could result in loss of coverage.

These developments highlight the need for proper patient insurance verification and policy coverage in physicians’ practices too. The task involves checking details such as co-insurance, co-pay, deductible, and annual out-of-pocket limits to establish the patients’ financial responsibility before their office visit. The patient’s insurance carrier has to be contacted to ensure the information on the patient’s insurance identification card is up to date and valid for that date of service. This is a time consuming task requiring the dedication of well-trained personnel, which is why most physicians choose to rely on professional insurance authorization services.

Physician billing companies that perform patient eligibility verification have a well-oiled procedure in place. Their insurance verification specialists

  • Review the physician’s schedule to identify new as well as established patients before their appointments
  • Contact patients to obtain the details needed for verification purposes such as the name of third-party payer, verification phone number, member’s name, member’s ID, and member’s date of birth
  • Identify primary and secondary medical coverage
  • Check with the payer as to whether the patient’s plan will consider an in-network provider or out-of-network provider; if the physician is out-of-network, the patient’s will need to pay a larger proportion of the bill.
  • Obtain authorizations from the insurer for specific treatments if necessary
  • Update the billing system with all the details

With a medical billing company handling their insurance eligibility verification process quickly and accurately, physicians can expect to benefit from reduced claims rejections, improved patient collections at the point of care, and improved cash flow. This also allows them to free up their staff for other core activities.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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