Eligibility and Benefits Verification

Patient payment collection service

Eligibility and benefits verification is the crucial first step in the Revenue Cycle Management process

Apart from human error, a major cause of claim denials is incorrect or outdated insurance information. Appropriate co-pays not received at the time of service are difficult and time-consuming to collect later.  

The Patient Eligibility Verification Process

The verification process starts by obtaining basic information from patients from their insurance identification card. This is compared against the provider and plan data to validate: 

  • Name and address information

  • Effective date of coverage

  • Current patient and dependent eligibility

  • In-network coverage

  • Type of plan

  • Payable Benefits

  • Procedures covered by the plan

  • Co-pay, deductible and co-insurance patient responsibilities

  • Claims mailing address

  • Referral and pre-authorization requirements

  • Pre-existing conditions clause

  • Maximum daily and lifetime benefit amounts

Ready to take your Practice to the next level?

Benefits of Insurance Eligibility Verification

Consistent insurance eligibility verification means your medical practice submits better claims for payment, and receives more upfront payments from patients. Other benefits include: 

Increased Reimbursements

Lack of rigorous insurance eligibility verification negatively impacts reimbursements your medical practice can receive. Reducing errors and submitting claims within payer guidelines reduces denials and speeds payment.

 

Improved Office Efficiency:

Patients who understand their responsibility will make payment at the time of their visit. If non-covered patients receive care, extensive staff effort may be invested before the error is fully realized. Patients who thought they had coverage may become dissatisfied if they receive an unexpected bill.

Better Revenue Cycle Management:

Since eligibility and benefits change so quickly, a lack of follow-up prior to visits can lead to a significant loss of revenue. Consistent and accurate eligibility verification is essential to a healthy revenue cycle.

Reduced Administrative Burden:

Upfront effort on verification saves a lot of post-visit effort working denied or delayed claims. Talking to patients prior to their visit is easier than serving as a liaison later between them and their insurance.

Why Choose Us?

PrognoCIS has two decades of experience in the Electronic Health Record market. Features we offer to optimize your returns and shorten your revenue cycle include: 

Software systems with integrated real-time insurance eligibility, including co-pay, co-insurance, and deductible balances. Strategically placed icons at all touchpoints enable your practice to easily check insurance coverage in real-time.  

The PrognoCIS Batch Eligibility feature removes the manual efforts of eligibility verification.

Eligibility is automatically verified for all scheduled patient appointments. Simply set a schedule for your auto-check protocols, so the front office can proactively seek required information from the patient. 

Automatically schedule eligibility checks at various care and billing touch points through easy-to-access eligibility responses button.

Check/compare/flag and update demographic data against insurance records. Look for any mismatch in address, spelling, or subscriber details which could prove vital for patient collections. Get demographic insights on crucial patient validation information, to make more informed practice decisions. 

FAQs

Eligibility verification is the process medical practices use to check whether a patient has active coverage with an accepted payer. Insurance companies regularly make policy changes that could affect patient eligibility. Coverage can also change due to Medicare eligibility, Affordable Care Act marketplace renewals, or employment changes. It might be eliminated due to non-payment, changes in the family situation, or a dependent coming off a covered insurance plan.  

Confirming coverage for new patients should be completed in advance of the first visit. This ensures that the practice is within the allowable network, and outlines any co-payment/deductible information. The patient then arrives prepared to make payment. 

Verify insurance eligibility prior to patient visits to confirm coverage is in force, and that the patient is covered. 

Dependent status may change for spouses or partners due to death, divorce, or separation. Children may be covered differently based on a divorce settlement, age of the policy, or obtain their own coverage.  

Software FAQ

Learn more about eligibility & benefits verification

What People Say

I really appreciate the ability to rely upon PrognoCIS to handle the billing. It allows me to concentrate on providing patient care.

Gwynn, thank you for your personal assistance and willingness to coordinate, manage, and explain billing.

Karen McGraw

FNP, LITTLE POUDRE FAMILY MEDICAL

If you haven't already, consider using a medical billing software for your practice.

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All our promotional offers are as individual and unique as the practices and clinics we support.

We look forward to exploring the potential benefits and offers prognoCIS has for you.

Please fill in your details with the best contact email and phone number.

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