An efficient revenue cycle management process is essential to achieving financial objectives in any healthcare practice. Although several critical success factors determine the efficiency and effectiveness of the revenue cycle, each is interdependent and contributes to its success or failure. The first critical component in the revenue cycle management or medical billing process is eligibility and benefits verification, which significantly influences financial outcomes.
The insurance company denies the claim if a patient’s insurance coverage is inactive at the service date or if insurance benefits do not cover the service procedure. Every claim denial by the payers is a revenue loss to the provider or may lead to a substantial financial burden to the patient. An efficient and optimized medical billing process significantly improves claims reimbursement and revenue.
What is the eligibility & benefits verification process in revenue cycle management?
A well-defined revenue cycle process starts at the patient’s appointment scheduling and registration stage, where the front desk office gathers pertinent information about the patient’s demographic details, insurance, and possible service requirements. This information is used to verify the patient’s primary and secondary insurance, benefits coverage, and coverage limitations, identify prior authorization requirements, and determine the patient’s financial responsibilities regarding deductible, copay/coinsurance, and patient’s out-of-pocket (OOP) expenses. The underlying premise of eligibility verification is to ensure patients have adequate insurance coverage for the intended medical services.
Why is eligibility & benefits verification necessary?
Inaccuracy in insurance eligibility and benefits information leads to claims denials, reducing overall revenue and making the practice highly vulnerable to financial sustenance. Incorrect benefits verification invariably overlooks any requirements for prior authorization for the services, leading to billing staff failing to apply for prior authorization on time. All these imperfections at the pre-visit stage add administrative burden and operations costs by engaging billing staff to work on denial claims.
Every patient-focused service must inform patients about their financial obligations before the planned medical services. This improves patients’ satisfaction, as an efficient appointment scheduling and registration process involving proper benefit verification and intimation to the patients about their coverage and out-of-pocket costs reduces potential confusion.
Numerous studies on healthcare providers involving claims denial show that more than 20% of claims are denied due to incorrect eligibility data. Many of these claims are not refiled for various reasons, leading to financial loss to the practice.
What does RCM Workshop do to improve the eligibility & benefits verification process?
The best practices and workflow for revenue cycle management (RCM) at the RCM Workshop focus on optimizing the medical billing process at each stage, from eligibility and benefits verification to accounts receivable management. We believe in identifying issues and bottlenecks at the origin to prevent error at a later stage, thereby optimizing and ensuring the success of the revenue cycle process.
Our eligibility specialists utilize all available and necessary tools to verify information and ensure that clean claims are submitted the first time and paid on time. We identify the stages in the revenue cycle where eligibility verification adds tangible benefits.
Our well-defined process ensures accuracy and precision in eligibility and benefits verification. The essential components of the eligibility verification process are:
- Gather patient’s demographic and insurance information
- Verify primary and secondary insurance in case of multiple insurances
- Check whether the insurance policy is active and confirm the effective dates.
- Verify benefits coverage details to check whether services, including specific procedures or DME, are covered.
- Identify plan exclusions.
- Determine patient responsibility, such as deductibles and co-payments or coinsurance
- Check prior authorization requirements for the services to be rendered.
- Determine coverage limits for any caps or limits.
- Check for provider network status, whether in-network or out-of-network:
- Patient intimation and acknowledgment regarding the patient’s financial obligations.
Our eligibility and benefits verification process is well-defined and standardized, ensuring a predictable and consistent quality outcome. Our analytics-driven approach provides the highest level of productivity without compromising on quality parameters.
How does outsourcing eligibility and benefits to RCM Workshop benefit a healthcare practice?
Our eligibility and benefits verification process aims to minimize claim denials and maximize the number of clean claims submissions. A more significant percentage of clean claims results in higher and faster payments, improved cash flow, and reduced administrative costs, boosting the practice’s financial health.
- Faster turn-around-time for eligibility checks and benefits verification
- Quality control mechanism to provide accurate information
- Significant reduction in denials due to eligibility issues
- Higher rate of clean claims submissions
- Faster payment cycle and improved cashflow
- Improved clarity on financial responsibilities for patients
- Improved patients’ payment at the time of service
A revenue cycle service that delivers the highest value
In the dynamic and ever-changing healthcare landscape, revenue leakage due to the increasing trend of claims denials is the silent killer but does not get proper attention. Our revenue cycle management service is built on the premise of “Prevention of error at the origin” and consistently delivers accuracy and efficiency. We evaluate our process performance regularly based on critical metrics and encourage our clients to measure our service delivery performance using any industry benchmark.