Tuesday, March 13, 2012

Checking Eligibility

Before a provider sees/treats a patient, the office staff must check the patient’s insurance eligibility. Checking eligibility is the process of contacting the insurance to inquire about the patient’s coverage. You will want to know if the insurance policy is effective and what benefits the patient has for what types of services.

There are several ways to check eligibility from a phone call to electronic verification. Some practice management systems have an EDI eligibility checker, these are usually very easy to operate and often work based on the daily schedule. Check your practice management systems manual to see if your system has this capability and how to use it. If that is not an option, your clearinghouse may have the capability on its web site.

Eligibility via your clearinghouse may be an additional charge so be sure to ask first. Understand that the practice management system eligibility is run through your clearinghouse, so there is no reason to try both the practice management system and the clearinghouse. Choose the one that is available and most functional.  The one drawback to the practice management system and clearinghouse eligibility check is the limited insurances that are available for the direct connection for eligibility. This is really not too much of a problem though, because the fewer insurances that you have to call the better.

The next method for checking eligibility is via the insurance’s web site. This often requires advance registration but is very useful. The drawback here is that you have to keep moving between web sites and not all insurance web sites have this capability yet (especially smaller insurances like local union carriers). Lastly, is the good old fashioned phone call, this is the least efficient way to perform eligibility checks but a method that cannot be totally avoided.

I recommend a combination of the above. If the practice management system or clearinghouse has the ability use it for as many patients as it is able to do. Chances are several patients will not be reviewed, so for those try the insurance web site or a phone call.

Regardless of how you find the information, checking eligibility is an important step. Many patients do not understand their insurance and therefore they may give you the wrong information. That wrong information will result in claim denial. Also, there are patients who will provide expired insurance knowingly to avoid having to pay for the visit. The information you need to check patient eligibility will vary depending on the provider specialty, what procedures may be preformed, and the insurance company’s requirements.

Here’s what you will need to check eligibility.
  • Your practices name and the doctor name
  • Provider’s tax id number and /or NPI numbers
  • Date of service
  • The procedures that are going to be preformed on the patient (If you are not sure, check the chart to see if the last visit made any indication and if there is no previous entry ask the office manager what the usual protocol is for a new patient.) 
  • Patient name
  •   Patient date of birth
  • Patient’s insurance identification number
  •  Patient’s insurance group number

Once you have the necessary information contact the insurance. If you need to call them, the telephone number is generally listed on the back of the patient's insurance card. Here are some examples of what you need to ask the insurance about the patient's coverage prior to the patient's appointment:

  • What is the insurance policy’s effective date?
  • Who is the patient’s primary care physician?
  • To what address should claims be mailed?
  • What is the patient’s co-payment amount? Is there co-insurance?
  • Is there a deductible due? Has the deductible been met (paid)?
  • Does the patient’s policy require referrals for specialists?
  • Does the policy require precertification?
  • What number do we call for precertification?
  • Is the patient required to go to a specific laboratory for blood work?
  • Is the patient required to go to a specific facility for radiological tests?
  • What is the insurance representative’s name?
  • Be sure to date and initial your notes from this conversation. 


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