How Accurate Patient Eligibility Verification Nips Claims Denial in the Bud

Patient eligibility verification at the front desk is crucial as it ensures accurate and timely submission of information on patient coverage at the very initial healthcare provider stage.  Patient payment responsibility too can and should be fixed at this early stage.

Front desks should also be equipped to check details like out-of-network benefits and information on insurance validity while performing upfront patient eligibility verification. This will help to cut down claim delays and denials.

Let us discuss some of the top reasons for claim denials at the patient eligibility verification phase and see how providers' front desks can help address these challenges upfront.

Common Causes for Claim Denial at the Frontdesk

• Typos
• Incomplete Patient Demographic information
• Claim Filing Delays
• Expired Policy
• Out- of - Network Services
• Duplicate Claim
• Exclusion Criteria
• Delayed Paid Premium
• Lack of Referral From a Specialist

Incomplete Demographic Information

Incomplete or incorrect demographics may seem like a simple issue, but it can lead to a huge backlog of claims. Even a typo in the patient name’s spelling, mistake in the address of the patient, or wrong keying in of the medical plan can lead to claim denial. The health provider desk staff should, therefore, scrutinize such information more closely and avert any problems that may adversely affect claim submission.

The helpdesk should match the data in the database with the information filled by the patient in the form, and where there are disparities. Corrections should be carried out immediately.

Correct patient demographic and cover data collected at the front desk reception will enhance the patient screening process, and the helpdesk or reception at the healthcare facility will have more control over the patient's eligibility process. This applies to both manual and automated processes. In fact, embracing automated processes will help to reduce input errors.

In addition to the claim data, the front desk at a healthcare facility can play a major role in curtailing fraudulent claims.

Delay in Filing the Claim

In a typical scenario, the insurance providers permit a period of 60 to 90 days for claim-filing from the time of the procedure/operation. However, if after a certain time, the claims are not filed or the claim submission is made after the stipulated time, there may be a claim denial. In cases of a medical emergency, it is always a good practice to keep the insurance provider in the loop about the patient case details.

Hence, it is the healthcare service provider’s helpdesk that can play a vital role in averting financial liabilities by either intimating the payer about the delay in filing claims or informing the insurance provider about lapses that may lead to the delayed filing of claims.

Updates in the Insurance Plan

There are many life situations that cause individuals to change their healthcare coverage. That apart, it is a good idea to review the details of a new plan when updating your insurance policy. It is particularly critical if you have been diagnosed with a severe illness, as the cost implications can be shocking.

When a patient updates his or her insurance plan, the healthcare provider desk needs to update the patient details on their system and conduct a fresh eligibility verification. Failure to do so may lead to claim denials.

• ‍Expired/Terminated Policy
  ‍In some scenarios where the patient’s policy expires, the patient is no longer covered under insurance and leads to a straight rejection of the claim. The desk staff have the ability to check the validity or expiration of an insurance policy upfront and can prevent such claims from passing on to the next stage, thus adding efficiency to the claim cycle.

• ‍Out-of-Network Insurance Plans
  ‍Most insurance providers have prescribed in-network and out-of-network repayment arrangements. However, some insurance providers have restrictions on the cover, and it may be limited to a specific state or regional area. The health desk staff can check upfront a patient’s insurance cards and validate eligibility very closely to keep denials at bay.

• ‍Lost Claim
  ‍It does not matter who missed it, but if the claim is misplaced and does not make it to the insurance provider’s system on time, the claim will be rejected. The provider helpdesk should put in place a weekly follow-up best practice. This will ensure they do not lose out on lost claims. ExclusionExclusion Criteria EveryEvery insurance coverage has some exclusions that will not be covered under any scenarios. These may range from diseases to certain procedures. Not all policies have similar content on their exclusion list. Therefore, it is prudent to review the exclusions to avert unexpected claim denials later. The helpdesk can follow a standard practice of checking on the inclusions and exclusions regularly to avoid such claim denials.

• ‍Delayed Paid Premium
  ‍Insurance providers will only consider claims of patients who have active insurance policies. Surprisingly there are numerous individuals who do not have the slightest clue that delayed premium payments will lead to policy lapse. Once the policy lapses, patients will fall out of coverage, and the policy will not be applicable to them; this will lead to claim denials. As a result, the payments will not be reimbursed. Checking policy details upfront will surely prevent such situations.

• ‍Referral From a Specialist
  ‍Some insurance providers require authorization and reference from the primary care specialist or similar medical specialist for some procedures. If treatment is carried out without a referral, the medical claim will be denied. In such cases, the desk staff needs to communicate with the insurance provider the details of the patient so that they can treat this as a special case and take necessary action according to their policies.

‍Conclusion

‍Verifying the eligibility of patients is of extreme significance as it directly affects the cash flow of healthcare practices. Eligibility verification upfront gives the details of the insurance coverage, co-pays, and deductibles at the provider level; thus, there will be a decline in the number of claim denials or delays, fewer slip-ups and minimal need to follow-up.