Well-organized insurance eligibility verification helps physicians identify and address any coverage issues prior to patient treatment.

1. Insurance Verification – A Critical Component
of Revenue Cycle Management
Well-organized insurance eligibility verification helps
physicians identify and address any coverage issues prior to
patient treatment.
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Failure to verify patients’ health insurance is one of the most common reasons for denied
claims, leading to lost revenue, payment disputes with both payers and patients, and audit
and compliance issues. Practices need to carry out insurance eligibility verification prior
to the patient’s appointment to establish the validity of the patient’s coverage with the
insurer and to verify the patient’s financial responsibility, including copayment, coinsurance
and patient-specific remaining deductible, and annual out-of-pocket limits.
Common reasons for denials related to lack of proper insurance verification include:
 Enrollee is not eligible on the date of service billed.
 Enrollee not covered for this service.
 Procedure requires authorization or services were not authorized.
 Policy maximum has been reached.
 Qualified Medicare Beneficiary (QMB) Only Enrollee. Medicaid coverage limited to
Medicare Part A and B premiums, deductible and coinsurance.
Practices that opt for professional insurance verification services would rarely see such
denials. Companies providing these services have a knowledgeable team specialized in
verifying patient benefits as well as carrying out preauthorization for procedures that need
prior payer approval.
Benefits need to be verified for both new and established patients. The cycle starts with the
first contact with a new patient. The following insurance information will be verified:
 Patient’s name and date of birth, ID, social security number
 Name of insurance carrier, contact information for the insurance company including
phone number, website and address for submitting claims
 Whether the provider (physician) is in network
 Whether the patient has a deductible
 Whether the patient has co-insurance, and of yes, the percentage
 Whether the patient has a co-pay and the amount of the co-pay
 Coverage start and end dates
Once this information has been obtained, the carrier will be contacted to verify whether the
patient is covered by the insurance, effective dates of coverage, and in-network or out-of-

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network coverage. If there are any problems with regard to these matters, the patient can
be informed.
Checking insurance benefits for established patients is also important as personal
information and insurance coverage can change over a short period of time. For instance,
employers may change policies or employees may switch plans. If there is a change in
information/insurance for an existing patient, the procedure to verify their benefits should
be done before providing care.
Medicaid patients would require an additional verification prior to each appointment to
identify any changes in their Medicaid plan since their last visit. States are responsible for
administering their Medicaid program and rely on private insurers to implement them.
Insurance verification service providers will check the websites of these private payers to
understand their policies. Nevertheless, physicians should know that people who qualify for
Medicaid assistance and are denied coverage by the third party payer may not be able to
pay for their care.
All documents pertaining to insurance should be checked for accuracy and legibility. Failure
to do so can lead to billing and compliance issues. Things to verify include whether the
financial policy and all the other forms have the patient’s signature and are dated. Copies of
the insurance card and the patient’s ID must be filed in the physician’s office.
Insurance verification can be done over the telephone or using electronic systems.
Professional medical billing companies have well-organized automated processes in place
for collecting and verifying insurance eligibility. Leveraging these services can go a long way
in avoiding eligibility related denials.