Eligibility Verification for Healthcare: Process, Priority, and Optimization

Revenue cycle management is the most basic work procedure of the Healthcare industry. It is the process that manages both the data and revenue of the organization. Just like proper data storage is critical to the industry, revenue management also needs to be looked upon meticulously. This brings in the need to prioritize eligibility verification. The entire process if optimized can reduce the pressure on other processes like denial management, claims transmission, etc.

The stringent nature of revenue cycle management is necessary to ensure that the revenue flow is maintained. This careful eligibility verification forms the primary skeleton of the cycle. Let’s have a wide-angle view of how eligibility verification works.

The working

The eligibility verification process is broken down into four major steps as follows :

Patient routine

This is the first step where a patient is booked for appointments. The appointment can be of checkup, primary services like x rays and MRIs, or secondary like operations. Here the patient is first logged into the system of the hospital and data is then collected upon the receivable services.

Patient registration

Here the vital data of the patient is further stored. This is where data optimization begins. Essential data useful to the organization are stored and the rest are omitted. Name, age address, previous illness, allergies, and diagnosis are some vital information that is stored in the patient’s file.

Verification of eligibility

Here the entire data of the patient is sent to the insurance company for insurance claim correctness. It is essentially a checking point to determine whether the patient possesses the insurance. This step has to be ensured by the service provider of the Healthcare industry.

Pre Authorization

In this step, the information is collected from the insurance company. The insurance sends the eligibility of the patient for the listed services. This entire step is very important for the healthcare industry to ensure payback after the services are offered.

Knowing the process itself does not eradicate our thoughts as to why the eligibility verification process is so important. So we also bring you the benefits of it. Below are some of the most advantageous factors for eligibility verification.

Error-free claims transmission

If the information is corrected and checked at the time of eligibility verification, there lies no issue of wrong data entry at the time of claims transmission. The information if contains some error it can be corrected at the beginning of the revenue cycle to prevent any further denials. This way the accounts receivable section is minimalized.

A rise in cash flow

Just like we mentioned before if the transmission of the claim is error-free, there will be lesser denials. This all adds up to the fact that cash flow will rapidly increase which is benefitting the company.

Efficient work

Again considering the error-free claims submission, we can deduce that the efficiency of the work is improved. This not only brings a good reputation to the service provider but also builds a strong brand image for the company. Improved employee efficiency is a clear sign of the growth of the company.

Self-awareness of the patient

Most times the patients are in a state of misunderstanding that their insurance covers all the medical services which are not true. This comes as a shock to them at the time of billing when they are charged for extra services taken and they feel cheated. Eligibility verification can pre-approve the listed services and make patients aware of the services they are entitled to for free. It also provides information regarding cover status, active/inactive status, eligibility status of the patient before the medical services are availed.

After the quick trip of the advantages of eligibility verification, we are left wondering how to optimize it. We have brought you some basic details curated with utmost importance so that it helps you in battling your way to being the best.

The very basic step would be to regularly check the scheduling of patients with effective scheduling software. The next step would be to conduct brief discussions with patients about insurance coverage and obligations. The most important point to remember is to keep updating the patient’s information in the formatted database. Nowadays real-time eligibility verification is also available to make the eligibility process work more smoothly.

The entire process from scheduling a patient to pre-approving the insurance claims needs to be done by a more focused staff to ensure no errors are let loose. The only way we can thrive to be the best is to make our work better each day.

Thank you for reading the article. I hope it was well informed. In case you want any information regarding eligibility verification, kindly contact us. Team SYANTHY will be happy to help you and make your work easier. It will be our immense pleasure if you give your valuable feedback in the comment section. Please share this article with your loved ones and professional circle if you like it