How Wrong Insurance Eligibility Procedures Can Cost You Thousands Of Dollars A Year

Did you know that a 20‑patient/day clinic can lose ~$47,000/year just from inefficient eligibility workflows—not including denial rework costs?

Now, lets rewind and discuss insurance eligibility.

Insurance eligibility or verification is the process in which one investigates patient's insurance benefits to know:

1. Your status with their particular insurance plan (In Network or Out of Network)

2. If they have a deductible they would be responsible for

3. If they have a coinsurance they need to pay at the time of visit

4. If they have a copay they need to pay at the time of visit. 

5. If referral and authorization is needed prior to insurance covering the services you provide

These things are important to know because it will tell you if you can or cannot see the patient, and if the patient has a financial responsibility to meet with you PRIOR to you seeing them. 

Many practices that do not perform insurance eligibility prior to the visit lose money because they either do not collect money upfront, leading to patients not paying outstanding balances OR seeing patients whose insurance they are not contracted under, resulting in not being reimbursed for the services rendered. 

Believe it or not, this happens a lot. 

So you need to have a strong team to be able to verify patients insurances prior to each visit and it needs to be performed EVERY time you are going to see this patient as insurance plans can change from visit to visit.

Although it is a tedious process, it guarantees that you know you are getting reimbursed PRIOR to you seeing that patient. 

Insurance verification requires either calling insurance companies, which consists of long hold times and sometimes inaccurate answers from representatives that do not understand much English OR browsing through 10 different insurance portals which can be time consuming BUT...

There is a great tool called CoveriCheck which automates access to various insurance portals at a click of a button, cutting down the process time and decreasing overhead for a process that depending on your patient load can be very costly. It also simplifies the results report which makes it easier to interpret. 

My advice: Ensure your staff takes important attention to the insurance eligibility process to avoid you losing thousands of dollars due to 1 single mistake.