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  • Ernest Sari

Revenue Cycle Management - Insurance Eligibility

Insurance eligibility verification serves as a foundation to RCM (Revenue Cycle Management) after the front-end gathers information from the patient or the referring physician. To maximize your practice's profit, it is important to verify that the patient is currently covered by their insurance plan and to make sure that your practice is contracted with the insurances that your patients have.

Key factors to consider when running eligibility:

  • Date of Coverage (will the patient be covered for his/her upcoming visit)

  • Type of Coverage (if the patient has HMO, make sure your practice is covered with the affiliated IPA/Medical Group)

  • Benefits Coverage (s the patient covered for the type of service that was provided)

  • Co-pays, Deductibles, and Co-Insurance

Once eligibility is confirmed, this should always be documented in the chart and re-verified once the patient is in the office at the time of visit. It is important to run eligibility during each of the patient's visit to ensure that they are still covered under their insurance plan, and to make sure that the claim that is sent out for the visit will be paid.

Why is running eligibility important?

Running eligibility is a critical step because it has a huge impact on other stages of the RCM. For example, if your practice fails to run eligibility on a patient's second visit and the patient happens to be termed at the time of visit, the claim that is submitted for that date of service will come back denied. More time will be spent re-submitting the claim and waiting an additional 14-30 days to see whether your claim has been paid or not.

Running eligibility ensures that your claims are paid on time and that you are submitting a clean claim-- claims with accurate data. This step should be implemented and monitored to maximize your practice's profit in a timely manner, and can potentially streamline the RCM.

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