Verifying patients' eligibility for insurance is an essential task that is too often time-consuming, frustrating and costly for a medical practice. Numerous telephone calls to and from insurance companies and imposing stacks of claims affect both the profitability of the practice and the productivity the office staff. The eligibility check reveals a variety of information, such as extent of patient coverage, specifics of the health plan, identification of the primary care physician, and IPA (Independent Practice Association) linkage.

Three out of every four insurance denials are due to problems with eligibility verification: your staff has to spend a lot of time on resolving issues and on bill collection, resulting in delays in payment, decreasing the practice’s cash flow. According to a survey by AMA Council on Medical Service, 42 percent of physicians surveyed reported that over 10 percent of their claims are denied by managed care plans retrospectively. For more than one in eight physicians surveyed, denials represented 20 percent or more of their claims, while 39 percent said more than 10 percent of their claims are down-coded. These denials resulted in a monetary loss for almost three-quarters (74 percent) of the responding physicians, with 55 percent reporting losses of more than $2,500 in the previous 12 months. These figures indicate that patient eligibility verification forms an integral part of both the administrative and financial aspect of the clinical workflow.

Digital solutions for electronic verification of the patient’s insurance data are, however, making the process more efficient by helping to manage costs, free up staff time, by decreasing the rate of insurance denials and write-offs, and by speeding payments. Many providers are now offering access to their database of enrollees through the internet to help the medical office verify that a patient is actually covered. This is more direct than just checking the patients' insurance cards, which are rarely stamped with the eligibility expiration date.

Verifying through the Web:
Online insurance eligibility checking service enables the medical office to check a patient’s current eligibility for healthcare benefits under a specific payer plan. An authorized user simply logs on to the Website and performs an eligibility search- once complete; a report will indicate whether or not the patient is eligible for the service.

Integration with EMR
It is advisable for the practice to determine the eligibility of the patient before he arrives at the point-of-care. It is important for the medical practice to run the verification at least 1 day in advance from the patient scheduler. Integration of the online verification with the Patient appointment scheduler in EMR is a recent step in this direction. An integrated module automatically runs the verification process for all patients scheduled for visit. The system automatically checks insurance eligibility before the patient is scheduled for a visit. In this way, the practice is able to identify problems, if any, and address the issue when the patient arrives. Integrating the online verification process with the scheduler also serves the dual purpose of setting up patient reminders and eliminates data re-entry in the patient demographic details while capturing data.

Fewer Rejected Claims:
Incorrect provider and patient ID numbers are most often the cause of rejected claims. Online eligibility checks eliminate claim rejections by verifying members' numbers before submission of payment claims. Doctors no longer face concerns of lost billing due to delays or errors in ID numbers.

Accurate Billing:
An integrated system provides accurate determination of the patients co-pay amount and deductibles. It sets patients coverage expectations and reduces the risk of uncollected balances. The system eliminates the need for paper transactions and the clinic is able to avoid denied claims at a later stage.

The entire process starting from scheduling of appointment, thru insurance verification and setting up reminders takes place before the patient reaches the point-of-care. Integration of these processes with EMR facilitates seamless flow of information from the start through the end of the patients’ care and final submission of claims for payment. The practice achieves both effective work flow and increase in cash flow by this manner.