Question

What is verifying eligibility of services and why is it important?

What steps would you take to verify eligibility of services?

What is a precertification or preauthorization? Why do we as medical assistants obtain them?

How would you as a medical assistant obtain a preauthorization for a surgical procedure?

What does a preauthorization provide and what additional information is good in the PA process?

Answer 1

Answer no. 1

It is imperative that medical care providers understand the importance of insurance verification services in the healthcare industry. It plays a major role in a hospital’s claims denial management program. Successful billing depends on successful eligibility verification. Health insurance verification is all about the process of checking a patient’s active coverage with the insurance company and verifying the eligibility of his or her insurance claims.

In order to avoid claim rejection, the verification process must be done before the patient is admitted into a hospital. Otherwise, it might lead to denials and need for rework. Patients would be ineligible for benefits when they provide wrong or outdated information, or when their policies have been terminated or modified. A simple error can result in claim rejection or denial, so you have to be sure it is being done correctly.Answer no. 2

There 3 ways

1. Verify Authorization

In most cases, a medical practice primary care provider will only be interested in whether or not the insurance coverage is in effect during the time of services, and check for the patient’s responsibility. A specialist should verify whether their services will require a referral or pre-authorization.

If the procedure was pre-authorized yet you waited too long to schedule the service, the window of authorization can be closed any time. This is normally the case for certain therapies. To dodge this denial, it is advisable to be cautious of the deadlines and always submit the claims as soon as possible. Authorization is normally open for less than 30 days.

When it comes to referrals, it is necessary for specialists to ensure their patients acquire referrals from their primary care givers before paying a visit to the office. This will avoid any surprises. But there comes a time when the documentation you provide differs from plan to plan. In that case, you must make sure all referrals are documented in the patient’s records, whether you will need them in future or not.

2. Verify Insurance Carrier

In normal cases, a new or returning patient who comes to a medical provider must bring along their insurance identification card. The front office should have a look at the insurance carrier to confirm that the information on the card is correct and up-to-date.

This crucial information can only be obtained by checking the website of the insurance carrier. Alternatively, you can also call a representative of the insurance carrier. There are clearinghouses and practice management systems that also have the ability to carry out real-time verification on patient eligibility.

3. Verify Patient Information

Insurance verification is a long process that starts at setting up appointments in advance and collecting insurance information beforehand. In that case, the office will be able to check the information before seeing the patient. Knowing the patient’s financial responsibility beforehand is important because the bill may be more than what the patient anticipated. Most patients just don’t like surprises.

When checking for information, eligibility and benefits, it is always best to have a form in front of you. This will help you make sure you don’t forget the crucial information. Some of the items to include on the patient form are;

• Name
• Date of birth
• Address
• Insurance carrier
• ID number
• Group number
• Referral required
• Deductible
• Insurance phone number
• Authorization required

Having this information before you attend to the patient will help you have a better reimbursement, and effectively check patient eligibilityAnswer no. 3

Most commonly, "preauthorization" and "precertification" refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug.

In the medical billing world, preauthorization, prior authorization, precertification, and notification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.

Depending on what the patient's coverage documents and the provider's contract with the insurer say, neglecting to obtain preauthorization can result in reduced reimbursements or lower benefits for the patient. Services that don't require preauthorization can be subject to review in some cases. Knowing which insurers require which preauthorizations can be complex, but your medical billing software and/or precertification tools provided by insurers can help medical billing specialists navigate the preauthorization maze.

.Answer.no. 4

If you are going to be admitted to the hospital, or if you are planning any type of surgery, medical procedure, or treatment, you might want to call your insurer to make sure it does not require prior authorization.

If it does require prior authorization, your doctor will need to contact the insurance company to explain why the surgery, procedure, treatment, or admission is necessary. That is often the only way you can be sure your insurance will cover it.