Patient Ineligibility and Lack of Authorization Creating More Claim Denials

by | Last updated Jun 19, 2023 | Published on May 30, 2016 | Insurance Verification and Authorizations

Claim Denials
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With value-based care, patient eligibility verification and insurance authorization have become key factors to reckon with in medical practice management. In fact, ineligibility and failure to get authorization are the major reasons for payment denials. Fortunately, with professional medical billing support and advanced technology, physicians can determine insurance benefits, avoid denials, and collect patient payments to improve their revenue cycle.

Two typical reasons given for claim denial that practices need to watch out for include: ‘patient not eligible’ and ‘service not covered’.

‘Patient Not Eligible’

What does ‘patient not eligible’ mean? This could refer to either of the following situations:

  • The patient does not have insurance with the payer to which the claim is submitted by the physician’s office
  • The patient is not eligible for the service because health insurance coverage ended

When experienced medical billing companies manage the physician’s revenue cycle, they ensure that that patient eligibility is checked when scheduling the appointment. Insurance verification is also done each time services are provided as a patient’s insurance can change. For instance, getting married, having a baby, adopting a child or losing a job can affect a person’s coverage. That’s why co-pays, deductibles and co-insurance need to be verified at each visit.

Service Not Covered

Such denial occurs when a claim is submitted for a procedure that the patient’s insurance company does not cover. To avoid submitting an erroneous claim, the benefits verification team in a medical billing company will check the coverage in the patient’s insurance eligibility response or contact the payer if necessary. This is done before the services are provided. Verifying benefit information also involves ensuring that the patient has not crossed the maximum number of sessions permitted (e.g., for physical therapy).

In all these cases, it is the patient’s responsibility to pay for the services provided.

Advantages of Professional Support

With insurance companies increasing premiums, cutting coverage, and increasing patient responsibility, insurance benefit verification has become more important than ever. Checking eligibility is much easier with professional support. Leading medical billing companies have a dedicated team of insurance verification specialists on the job. With expertise across major insurances, multiple medical specialties, and various types of claims, they will ensure that co-pays, co-insurance, deductibles and other out-of-pocket costs are verified correctly.

Partnering with the right company will save time and resources, avoid preventable denials, improve patient satisfaction, increase collections, and allow physicians and their staff to dedicate more time to care.

  • Natalie Tornese
    Natalie Tornese
    CPC: Director of Revenue Cycle Management

    Natalie joined MOS’ Revenue Cycle Management Division in October 2011. She brings twenty five years of hands on management experience to the company.

  • Meghann Drella
    Meghann Drella
    CPC: Senior Solutions Manager: Practice and RCM

    Meghann joined MOS’ Revenue Cycle Management Division in February of 2013. She is CPC certified with the American Academy of Professional Coders (AAPC).

  • Amber Darst
    Amber Darst
    Solutions Manager: Practice and RCM

    Hired for her dental expertise, Amber brings a wealth of knowledge and understanding of the dental revenue cycle management (RCM) services to MOS.

  • Loralee Kapp
    Loralee Kapp
    Solutions Manager: Practice and RCM

    Loralee joined MOS’ Revenue Cycle Management Division in October 2021. She has over five years of experience in medical coding and Health Information Management practices.