Insurance Verification Process

Insurance Verification Process

The complex nature of healthcare billing can be a great challenge for many medical providers. The insurance verification process proves to be a central issue in billing. We believe that verification is a critical step in both accurate billing and adequate patient care.

In turn, we’ve dedicated our guide to exploring some of the most important concepts of healthcare insurance verification. The sections below will delve into its significance and help explain the impact it can have on the financial health of medical institutions. We will also address common verification challenges, explore effective solutions, look through industry security regulations, and much, much more. 

Understanding Insurance Verification Process

Insurance verification is the procedure through which medical companies evaluate patient insurance coverage. Better said, insurance verification aims to determine a patient’s eligibility and whether or not their insurance plan covers the service in question.

The insurance verification process is an integral part of the financial health of medical providers. Skipping this step leaves medical organizations liable for revenue loss.

Insurance verification is done prior to a patient being admitted to the hospital or clinic. In cases where the insurance is denied, the patient is informed about the situation and asked if they can cover the expenses themself.

Insurance verification is a task that is usually handled by front-office teams. However, it can put a significant burden on your staff’s workday. At CLICKVISION BPO, we believe that outsourcing insurance verification can be a very cost-effective solution, especially for organizations that manage larger patient volumes. Outsourcing can offer your front-office workers time to focus on their core responsibilities and deliver better patient care.

Understanding Insurance Verification


The Importance of Patient Eligibility 

A successful insurance verification process could result in improved cash flow and greater patient satisfaction. Simply put, the reduction of claim denials results in improved cash flow. The math is pretty simple; fewer denied claims mean more approved claims, resulting in more money. 

On the other side, explaining to the customer what their insurance covers and what doesn’t cover helps patients stay informed regarding their insurance coverage and they are not left faced with any costly surprises.

Identifying patient insurance eligibility benefits both medical providers and patients. This process offers medical organizations better overall revenue cycle management, increasing their financial stability.

Minimizes Claim Denials

Claim denials leave healthcare providers in an unfavorable position as their only option is to inform patients that they will be required to handle the cost on their own. Consequently, such financial surprises usually result in a dissatisfactory patient experience.

Overall, we find that insurance verification plays a pivotal role in accurate billing. Since accurate billing is a key concept of revenue management, medical providers must claim responsibility and understand the value of verifying insurance coverage. 

Key Components of Insurance Verification

A successful verification process relies on several factors. Among these, we find the following to be most significant: 

Patient Demographics

Collecting patient information is the initial step of every insurance verification process. The reason is simple: with the needed information at hand, your employees may begin the verification process immediately. The type of information needed includes:

  • The patient’s name and date of birth
  • The patient’s address
  • The name of the insurance provider

Insurance Coverage Details

While personal data is crucial for the verification process, insurance coverage details are vital for the verification to begin. You’ll need to get:

  • Patient’s insurance ID
  • Policy number
  • Group number (if possible)
  • Insurance company details, such as their phone number, are also necessary 

Another important aspect of gathering such data is asking for a policyholder’s name. It often happens that the patient is not the insurance policyholder, which can be an obstacle when contacting the insurance provider. 

Policy Limitations & Benefits

Relevant patient details are only part of the verification process. In fact, healthcare organizations seek to gain accurate insurance data. The patient’s insurance plan and inquiring about certain authorizations, such as coverage limits, are all necessary patient details for more accurate verification. Asking insurance providers about the patient’s deductibles and when the policy expires is another practice that healthcare organizations should keep in mind. 

Insurance Verification Workflow

Verifying insurance can ensure a more comfortable operation of your organization and minimize the chances of claim rejections. But what does it take to verify a patient’s health insurance?

Collecting the Patient’s Insurance Information

First things first: collect the patient’s insurance information prior to an encounter. The contact is usually initiated by phone when the patient calls to set up their first appointment. While insurance verification might be the most time-consuming, it brings the best results. Although you may think all you’ll need to do is ask the patient which company insures them, there’s much more to it. When you collect the patient’s insurance information, besides the name of the insurance company, be sure to record:

  • The patient’s name and date of birth
  • The name of the primary insurance plan holder
  • The patient’s policy number and group number ID
  • The insurance company’s phone number and address

Typically, the first steps when reaching out to an insurance provider include confirming that you have the right company and presenting yourself. This exchange is usually swift, as many insurance payers have lines specifically dedicated to hospital administrations.

Remember to ask for a second insurance– if they do, complete all the steps for each one.

Collecting the Patient’s Insurance Information

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Contact the Patient’s Insurance Company 

Before the patient comes into the medical clinic, contact the insurance company to verify the information provided by the patient.

The patient verification process can take some time to complete, typically around 20 minutes if everything goes smoothly. However, it may take quite longer if there are some discrepancies between the information and the insurance company’s records. 

This is why we recommend initiating the interaction at least 72 hours before the patient’s scheduled visit.

The most common way of contacting the insurance company is by phone. Make sure you speak with an insurance representative, and ensure the conversation is conducted securely in accordance with HIPPA. The insurance representative on the other side of the line will ask you for the patient’s information (from name and date of birth to policy number and group number).

Or you could opt and seek online eligibility checking resources. Although we at CLICKVISION BPO use both contact outlets, we prioritize verifying information by phone and use online resources as a last resort due to the possibility of outdated information.

Ask the Right Questions 

Having all the details in place gives healthcare providers a solid foundation to understand the ins and outs of the patient’s coverage limitations and benefits. Once you’ve confirmed all the necessary information, ask about the insurance policy expiration date. Supposing it’s still active, collect information about the patient’s deductible.

But don’t stop here. Find out whether any sort of insurance authorizations are necessary before seeing the patient. Are there any unusual coverage limits or any other additional documentation? 

In some cases, authorization requirements are also a part of the follow-up. This means the medical provider must initiate the authorization process prior to performing the service. This will help minimize the risk of claim denials and other disruptions of revenue flow. 

Assuming everything went smoothly, record the information in the EMR.

Importance of Timely Verification & Submission

Scheduling the insurance verification process early on allows the healthcare organization to have all the necessary information before a patient arrives at the clinic. We find proper timing to be crucial in avoiding misunderstandings and further insurance issues. A well-timed verification contributes to an optimized revenue cycle, preventing issues such as claim denials, billing errors, and revenue loss.

Our years of experience showed that patients sometimes forget to inform us when their insurance changes. Because even a slight change in the insurance plan can lead to claim rejection, it’s a good idea to re-verify the patient’s insurance plan every month.

Challenges in Insurance Verification

Incorrect Patient Data

As we explained earlier, gathering patient details and insurance information are some of the most important aspects of verification. Consequently, obtaining accurate information proves one of the biggest challenges of this process. Common reasons for inaccurate patient data include human error and outdated records. 

As an effective way to address such challenges and reduce the likelihood of delayed or rejected claims, we recommend implementing a robust registration system. This system aims to update valuable patient information, such as insurance details and contact information, during each visit. Utilizing an electronic health records system with your insurance database is also a good way to streamline the verification process. 

Time-Consuming Process

Organizations often face time constraints, and verifying eligibility accordingly requires attention to detail and optimal time management. Relying on front-office tasks to handle verification issues often proves unreliable as they also have other duties they need to be devoted to. 

On the other hand, hiring an in-house team can be a costly investment. We recommend outsourcing this service and relying on a specialized third-party provider such as CLICKVISION BPO as a reasonable option. It can take the load of your employees and ensure the process runs efficiently. 

Training and Education for Staff

While outsourcing can be a reliable option, some healthcare organizations prefer to manage their workload internally. These organizations should be aware of the impact that staff training and education may have on the verification process. 

Insurance policies are often difficult to untangle and require a good understanding of coverage rules, variations, exclusions, and limitations. Such specifics can make the verification process increasingly difficult if your staff hasn’t been properly introduced to all the involved topics. 

Offering employees continuous education on coverage guidelines and policies can ensure your staff is well-informed and capable of reaching adequate decisions. Additionally, to ease the communication with insurance companies we advise installing a separate telecommunication line for this purpose. This can help promptly address insurance-related issues and speed up response. 

However, training in-house employees can be a costly investment. Outsourcing through a company such as CLICKVISION BPO can be a great alternative for those who don’t have the resources to invest in in-house hiring and training. 

Compliance Considerations

Staying compliant with privacy and security regulations is of key significance in the healthcare industry. Medical providers handle sensitive patient information and these should be treated accordingly during the healthcare insurance verification process. 

According to federal law, all healthcare providers must abide by Health Insurance Portability and Accountability (HIPAA) regulations. We believe setting secure data management protocols and educating employees on patient privacy is essential in verifying insurance.

Being aware of protected health information (PHI) can ensure a medical provider handles patient data properly during the verification process. This usually includes security measures such as encrypting data and regular audits. 

Compliance Considerations

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The insurance verification process stands as the guardian of accurate billing and smooth revenue cycle management in healthcare settings. Optimal execution of this verification process can help medical providers maintain financial stability and optimize cash flow.

Verifying insurance is performed by contacting insurance providers to confirm a patient’s eligibility. While it might seem straightforward, this process includes several challenges, such as collecting accurate insurance and patient data.

Outsourcing, robust systems for managing patient information, and staff education are just some strategies that can streamline this process.

With a strong background in the marketing industry and healthcare leadership roles, Filip is responsible for CLICKVISIONBPO's sales strategies and onboarding new clients. With a passion for sharing insights gained from his experience, he also shares valuable knowledge through industry related articles.

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