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Do you struggle to find time to check patient insurance eligibility and benefits?

Dec 25

What is Revenue Cycle Management (RCM)?

Revenue Cycle Management is the process that manages the financial record of the patients' daily visits. The medical billing software keeps track of all the economic holidays by the provider. It tracks all the patient care data from scheduled appointments or registration to the final payment of the patients. Many medical health organizations use this process for daily reports and reimbursements of the medical billing company. 

Patient eligibility and benefits verification is the process of determining the medical care practices and confirming data like copayments, deductibles, coverage, and coinsurance with a patient's insurance agency. It's a significant part of the revenue cycle management (RCM), which involves medical practices taking the record and ensuring the payments. By checking eligibility, rules can decide a patient's clinical insurance status preceding the arrangement and report segment data precisely on insurance claims. Moreover, focusing on eligibility advances the proactive behaviour of the patient, and it also prevents payment delays. Failing to check eligibility is a typical justification behind medical denied or dismissed claims. If you want to increase your medical practice rate and clean claims, you can outsource your medical services to get better results.

If you want to increase your medical practice rate and clean claims, or do you want to avail of outsourcing medical billing services, you must know the following. 

  • How does a medical practice check the patient's eligibility?

There are two methods of the eligibility verification process, which are as follows:

Manual and Electronic real-time checking are the two medical practices used in the patient's eligibility verification process. It is best to check the eligibility via electronic real-time at least 48 hours before the patient appointment. Electronic real-time eligibility is more efficient. If you outsource your verification process, you should hire some professional medical company to generate your high-level revenues. 

This method has specific steps which allow you to:

  • Before the patient's visit, get the insurance details and status of insurance. 
  • If a copayment is due at the time of service, ask for updates from the patient and their advice. 
  • Verify updated insurance and ensure the registration and check-Ins of patients. 
  • Request patients to update their primary care (PCP) and coordinate benefits (COB). 

While it is less effective, manual checking might be necessary for the insurance agency. There are detailed inquiries in regards to the patient's advantage plan. You can call the insurance company to know more details at the back of the insurance card or online portal.

  • What information is provided for the patient's eligibility coverage?

The patient eligibility coverage should provide the following information for every patient:

  • Patron name
  • Patient name
  • Patient's relationship with the patron
  • Patient date of birth
  • Patient gender
  • Patient member number
  • Group name and number
  • Plan type coverage date (policy effective date)

Payers might send extra data if accessible in the health plan records and proper coverage. It might include other insurance policies for impact, PCP, and eligibility status. In any case, the patient's eligibility cannot assure precise and accurate data. 

  1. When should eligibility be checked?

Practices ought to proactively look at the patient's eligibility. The best time is before the doctor sees the patient, preferably 48 hours before the visit. On the other hand, this cycle can happen whenever up until registration. Front-office staff ought to consistently inquire patients whether their insurance has changed since their last visit.

  • What are eligibility verification best practices?

To avoid rejected or denied claims in revenue, you should verify the patient coverage before using the Electronic Health Record software feature. 

There is a checklist of best practices that should follow before the visit of the patient:

  • Check for unplanned plans and flag the reports of patients. 
  • When patients have more insurance plans, you need to check the status of the insurances, which includes primary, secondary, and tertiary insurances.
  • Remind the Medical Billing Service company to update each payer's Cooperate of benefits (COB). 
  • It is better to verify the insurance coverage and medicare coverage of the patients above 65 years old.
  • The authorization is also needed to confirm the services of the patient insurance policy, even if some authority refers to it. 
  • Ensure the referred patients are approved by the authorization and entered in the list of correct visits. 
  • Check whether an advantage limit is recorded, determining the amount of the advantage remains. A few plans might have constraints for the dollar measure of each visitor repetitively and time where the administrations should convey (e.g., an advantage breaking point of 12 visits, with a visit cutoff of two trips each month). 
  • Medical companies should collect copayments, coinsurance, or deductible payments. 

Remember the following steps when scheduling the patients: 

  • The demographic details are the vital part. It should obtain as much as possible. Demographic information includes sex, race, Date of Birth (DOB), ethnicity, preferred language, which will affect the meaningful use of reporting.
  • Always check and ask the patients if they have changed their current demographic information or insurance details. 
  • What are the benefits of a standard operating procedure (SOP) for checking patient eligibility?

You suggest that you make a Standard Operating Procedures (SOP) for the eligibility work processes you use every day.  Documenting the work processes for your medical practice will give new employees information and finish responsibilities precisely and effectively. Also, the SOP record will advance cooperation across the workplace by assisting various jobs with seeing how their activities impact the revenue cycle management.


Overseeing eligibility and advantages confirmation can feel overwhelming, particularly notwithstanding the wide range of various basic revenue management cycle (RCM) steps. Yet, you don't need to do it all yourself! When you cooperate with UControl Billing Services, the best outsourcing medical billing,  you can profit from a group of experts devoted to helping you accomplish your income goals.