One of the challenges practices face is the incorrect capture of insurance information. This can happen for many reasons. First, the patient may supply the wrong or outdated information. Second, the practice could type the information in incorrectly. Either way, the claim will be denied.

Potential Solution

One solution may be to implement an Insurance Eligibility Verification feature using your Medical Billing Software. This feature can verify accurate carrier policy information before seeing your patient. With electronic insurance eligibility verification, you can feel secure knowing that the information is accurate. Inquiries can be submitted through the medical billing software system provider to the claims clearinghouse. In a matter of seconds you will receive a response.

The benefits of insurance eligibility verification are many:
Minimize Claim Denials – You lose money every time insurance eligibility goes unverified and claims are subsequently denied. Denials are a big cash flow problem for many practices.
Increase Collections and Cash Flow - Insurance eligibility verification permits you to determine if a patient is currently eligible for coverage from their insurance company with out making lengthy phone calls.
Reduce Resubmitted Claims - Every time you resubmit a claim you pay for a transaction. Even one error in payer information can reject the claim, and require a resubmission.
Accurately Set Patients Coverage Expectations - Enhances overall patient satisfaction and minimizes the risk of uncollected balances.
Provides Accurate Determination of CoPay and Deductibles.

Most Clearinghouses use the ANSI X12N format to transmit eligibility requests and responses. This format was implemented to comply with HIPAA requirements. Eligibility responses provide pertinent insurance policy and coverage data, including:
Patient demographics
Name and address of patients’ primary care provider so you may contact them.
Policy number
Policy detail - Coverage dates and status, to tell the provider’s staff whether a patient has insurance coverage on the date(s) healthcare is provided
Details on patient’s medical group affiliation - to help you to submit claims to the appropriate party when payment responsibility is shifted away from the health plan.
Deductible amount, deductible amount remaining for this year, and deductible year-end date.
Patient co-pay responsibility detail - to give you the correct co-payment required while the patients are still in the office.
Benefit information can include inpatient and outpatient benefits, pharmacy benefits, deductible accumulation, co-payment accumulation, stop-loss information, waivers and restrictions.

Since the healthcare provider is getting the most up-to-date information from the payer real-time, they can make intelligent decisions about the healthcare services being provided as well as payment arrangements that may need to be made. In addition, with this knowledge in advance, the practice has time to rectify any problem with eligibility prior to the date of service.

Enhance your staff productivity by avoiding manual insurance verification. With reduced denials for non-eligible status which results in decreased financial losses, electronic eligibility verification will benefit your practice now and in the future.

Lori Anderson, an independent consultant with LAtech, works with Antek HealthWare on their DAQbilling Medical Billing Software and LabDAQ Laboratory Information System projects, since 1991. With vast experience in the medical field her writing expertise includes laboratory operations, billing services, and private practice operations.

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