Revenue Cycle Management begins with ensuring that the patient and/or their insurance can cover the cost of the visit or subsequent treatment. Inadequate eligibility verification can lead to denials and/or payment delays. Through eligibility verification, practices can establish a patient’s medical insurance coverage status before their appointment, thus ensuring precise reporting of demographic information on insurance claims.

The process of verifying patient eligibility and benefits entails practices confirming details such as insurance coverage, copayments, deductibles, and coinsurance with the patient’s insurance provider. 

Revenue Cycle Rx provides real-time eligibility checking and when needed reaches out to Payers.

Utilizing electronic real-time eligibility checks a minimum of 48 hours prior to the patient’s appointment is considered a recommended approach. This approach enables you to:

1. Acquire insight into the patient’s insurance status and benefits ahead of their visit.
2. Request any necessary updates from the patient and provide guidance if a copay is required at the time of service.
3. Confirm that the insurance information is current and ensure the account is marked for a streamlined check-in process.
4. Prompt patients to update their primary care physician (PCP) and coordination of benefits (COB) information.

Revenue Cycle Rx follows this checklist before the patient’s appointment:

1. Check for inactive plans and mark those accounts accordingly.
2. Review primary, secondary, and tertiary insurance coverage. Remind patients with multiple plans to update their Coordination of Benefits (COB) for each insurer (Note: Medicaid is the last resort payer).
3. For patients aged 65 or older, it’s essential to verify if they have “traditional” Medicare coverage.
4. Confirm the services covered under the patient’s insurance policy and check for any required referrals or prior authorizations.
5. Ensure that any referrals and authorizations are not only approved but also accurately recorded in the system and linked to the appropriate visits.
6. Look for benefit limits, indicating how much of the benefit remains. Some plans may have restrictions on the dollar amount per visit or the frequency and timing of services (e.g., a limit of 12 visits, with a maximum of two visits per month). Note that psychiatric and substance abuse benefits information may require contacting the insurance provider’s customer service.
7. Determine whether a copayment, coinsurance, or deductible payment should be collected.

When scheduling the patient, we pay close attention to these steps:

1. Gather as much demographic information as possible. Some demographic details (e.g., preferred language, sex, race, ethnicity, and date of birth) are essential for Meaningful Use (MU) reporting.
2. Always inquire if the patient has experienced any changes in their insurance, such as acquiring a new policy or altering their coverage