Patient Eligibility: Why Every Practice Should Be Doing It All Of The Time

By editor
February 24, 2015

The main purpose of eligibility is to verify a patients insurance benefits. Eligibility is also the most effective way of preventing insurance claim denials. If eligibility is done properly you should get paid two to three weeks later. If eligibility is not done at all you risk claims getting denied for lack of coverage and either getting paid several weeks later or not paid at all.

Every practice should ask new patients for their insurance cards and verify current insurance with existing patients especially as the new year arrives. Then the practice staff should run an eligibility report on all scheduled patients.

The most important reason is to make sure that the patient does indeed have this insurance still current. Patient may not realize what insurance you have on file and may assume that nothing has changed. Obviously there are many reason why their insurance changed such as a change in their job, change in marital status or just a change in their insurance from one year to another due to plan changes. With everything else on a patients mind these changes may not be the first thing they are thinking when they come to your practice for their appointment.

So now you know that the patient has valid insurance and after checking the eligible dates you are confident that you can at least see the patient and get paid. Doing eligibility also tells you other valuable information such as the amount of their copayment, the remaining balance on their deductible, as well as if they are eligible for certain procedures that you may perform. If you are a primary care physician then eligibility can also confirm for you that the patient has selected you to be their primary care physician (PCP). Otherwise you risk not getting paid or billing them for a larger specialty copayment which they will not be happy about. You now have the time to ask them to change their PCP with their insurance or get the proper referral or authorization.

When should you do eligibility? Eligibility can be done at any point prior to the appointment but usually 1-2 days ahead of the appointment is a good timeframe. This timeframe will give you enough time to speak with the patient if something comes back amiss with their current insurance. Perhaps they will then be reminded of that new insurance plan they have and you will have just saved yourself some time and money.

How do you do eligibility? Eligibility can be done online for most insurance carriers. However your EMR or Practice Management system in coordination with your clearinghouse should have a very useful system in order to do eligibility for all patient at once for all online available plans. You should follow up with your system people in order to find out what is available. As an example, the clearinghouse that our company typically uses will allow you to run a report of all patients scheduled for appointments on a particular day. So instead of visiting the websites of several different insurance companies you will have the opportunity to go to one location to get eligibility on all patients. It doesn't get much easier than that so there really are no excuses anymore.

As I explained before, if you do eligibility you will know that you should now get paid. Even if you do not do eligibility most of your claims will get paid, however the ones that do not will present you with major issues. So if a patient uses invalid insurance and you are unaware of this the denial will come back a few weeks later and this is the first time you will realize something is wrong. You will now need to contact the patient somehow in order to get their proper insurance. Perhaps by phone or maybe by a monthly statement. This may take a few weeks as well because now the patient feels that they have already completed their obligations and may not be so quick to help. Now you rebill the claim to the proper insurance but perhaps you get denied again for timely filing. Now you have another headache to deal with. Even if you do eventually get paid it comes many weeks later and cost you more in time and resources figuring it all out. That is why doing eligibility is so worth it in order to keep your revenue cycle and accounts receivable in healthy shape.

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