The success and significance of medical practice revenue aren’t only associated with delivering exceptional patient care. Still, these professionals hold another critical role also—to ensure quality checks of patients’ insurance coverage to optimize care along with the relief of optimal reimbursement. However, conducting these quality checks during treatment provision may significantly disrupt schedules and workflow unless providers have access to certain key practices and resources for patient insurance verification. According to statistical data, more than 80% of medical billing errors are reported as a result of incomplete insurance information. That means the process is more attention-demanding than it sounds. This crucial guide sets out to inform you about essential prerequisites to manage both the accurate information collection from patients and providing treatment without compromise.
Understanding Why Effective Patient Insurance Verification is Crucial in Practice!
One of the significant reasons why patient insurance and eligibility verification are essential to be handled with careful attention span and scrutiny is the staggering number of denials! Incorrect patient details such as missing information, inaccurate service code, or even the modifier prompt 61% of primary medical billing denials. Combined, these account for 42% of denial write-offs.
For instance, a patient who receives services from an out-of-network provider is likely to get denied coverage by the insurer due to non-compliance with insurance. Plus, patients receiving treatment under more than one health plan are also completely or partially denied because of the lack of updation of their coordination of benefits. This and other many cases require professionals to ensure the quality checks of their patient’s insurance eligibility and coverage verification to identify the relevant payer for smooth claim submission. Plus, insurance verification also inserts patient trust and confidence with practice as they come across knowing their financial responsibility so that your practice secures timely payments.
Ensuring Accuracy in Every Step: The Best Strategies of Insurance Verification!
Following best practices in insurance eligibility verification ensures you handle this intricate process with accuracy and efficiency.
Establishing Effective Insurance Verification Protocols
Professionals must need to establish effective verification protocols such as a detailed checklist to collect the information. The checklist should be designed strategically to instruct the data collection of patient demographics, insurance details, and eligibility for coverage. When physicians cover these aspects before the treatment begins, they will face the lesser issues later on. However, the significant step of the process is to ensure verifying the eligibility of patients which leads to approaching the patient’s insurance company, assessing coverage, verifying co-pays and deductibles, and fulfilling other necessary tasks.
Know the Billing Policies of the Payer
Providing care at practice varies and so do the payer policies. To get the fair share of reimbursement, it’s first crucial to understand the payer policies and then effectively adhere to those principles of care to receive reimbursement set by these insurance carriers. For instance, if a provider offers services of different types including office or outpatient treatment on the same day, they must have a clear knowledge of what services can be billed and paid for by the insurance carrier in that case.
To make an example, Dr Smith, an Internist, diagnosed a patient with diabetes in the morning during a first patient visit. The day after the diagnosis, the same patient appeared to have acute chest pain. According to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.B, a physician from the same practice and specialty is not allowed to bill two E/M codes in one day. However, if the provider documents visits address unrelated problems and reports the medical necessity for the different encounters, the proper use of modifier 25 will ensure compliance with payer guidelines to get reimbursed for the dual procedures.
Understanding and Evaluating Payer Contracts
Make a careful review of insurance contracts because they contain information on the substantial revenue of your services. If you fail to critically understand the payer contract of negotiating terms with the insurance company, the chances are you may impact your revenue levels. Plus, get in contact with insurance companies by providing a detailed list of services you offer to streamline negotiations and supply fee schedules.
Another aspect is comparison which is the key to your understanding! Collect the data on both private and commercial payers and compare the rates they offer for the most common services. At times, commercial payers pay less than Medicare so there is a need to negotiate rates while contracting for services. Physicians should also gather data on local in-network providers to strengthen the comparison and ensure their practice adheres to the standards of the region across many health insurance.
Crucial Checks on Clinical Documentation Improvement
Clinical Documentation Improvement (CDI) is the term that gained popularity over the CMS’s implementation of Medicare Severity Diagnosis Related Groups (MS-DRGs). Such payment models are used to optimize reimbursement under Medicare’s Inpatient Prospective Payment System (IPPS). The purpose of the program was to help healthcare billing professionals ensure thorough checks of clinical records and coding accuracy. Hence, following the model, healthcare providers are responsible for maintaining the accuracy and clarity of medical documentation including the patient’s condition, diagnosis, treatment, and all the procedures that were performed during the appointment. Medical claims are the core for practices getting fairly reimbursed as insurance providers rely on the data provided in these documents. The more clear and detailed the medical necessity of patient treatment, the increased chances are there for insurance providers to compensate for the services rendered.
Why Accuracy is a Must in Practice?
Professionals can crucially maintain medical billing with all the above practices. However, any of the neglect to ensure accuracy in verification steps may lead to significant hurdles. Hence, these points will help you understand why accurate practice is the key above all and what are the steps to ensure all procedures in insurance verification have been conducted with significant scrutiny and care. Review the core aspects:
- Make sure you have gathered the information on patient demographics in detail during the patient scheduling and enrollment.
- Also, you should verify patient eligibility and insurance coverage while scheduling for the patient’s qualification to get treatment.
- To avoid errors in checks, carefully check all details during the pre-registration phase.
- Before providing services to the patients, validate their data accuracy and whether the information is complete.
- MedsNexus guarantees expertise in the verification of insurance coverage in detail. Plus, we verify insurance for multispecialty practices to ensure payment based on provider/ NPI.
- Audit and assess back-end processes also to ensure accuracy in insurance benefits verification.
- Confirm active insurance coverage, specific benefits, and exclusions during patient registration.
- Check policy validity and identify any limitations that may impact verification.
- Calculate what are the requirements of prior authorization to prevent delays.
- Document and record the entire verification process such as what was the communication with insurance providers.
- Make sure your patients are completely aware of their insurance coverage such as details on benefits, limitations, out-of-pocket costs, and policy details.
- Last, but not least, ensure the process is HIPAA-compliant by securing patient information and adherence to privacy and security standards.
The Wrap-Up! Guaranteeing you a successful Insurance Verification at Each Step
Join knots with MedsNexus (the industry expert for years)! We are the leading medical billing and coding company in Islamabad. Our medical coding services also deal effectively with the correct insurance verification for healthcare organisations. Be specific to each of the best practices to ensure success in your practice insurance verification as guided. Or, outsource the process with the best medical billing companies like MedsNexus. Stay proactive and optimize your RCM medical billing that is compliant with the industry regulations.
