3 Insurance Eligibility Verification Tips that Make a Big Difference

insurance eligibility verification

Insurance eligibility verification is extremely vital to the success of your medical billing efforts. Accuracy at this stage (which is also referred to as benefits or coverage verification) will determine how quickly your practice gets paid for services rendered. By letting the patient know upfront what their plan covers or does not cover, you reduce the risk of medical costs surprises, and your patients come to the medical office better prepared to meet those expenses.

An inefficient insurance eligibility verification process leads to delays in payment collection, higher claim denials, and dissatisfied patients. Your office staff will spend several hours reworking claims and trying to convince a patient that they now need to pay more than expected. Not only is this a highly stressful situation, but it also eats into your staff’s time and energy for patient care. Your practice also runs an increased risk of unpaid balances flowing into accounts receivable.

If you want to ace medical billing and claims collection, you must ensure that insurance eligibility verification is done precisely and timely. To achieve this, we recommend the following three tips.

1. Gather all the information before performing insurance eligibility verification.

Your patient may have changed jobs or taken a new insurance plan since they last visited your medical practice. Every request for an appointment is a chance to verify patient demographics. At the very least, you must ensure you have cross-checked the following information with the patient before verifying the insurance eligibility.

  • Patient’s name
  • Date of birth
  • Member subscriber number or the insurance ID
  • The patient’s phone number is on the insurance card.
  • Name of the primary policyholder, policyholder’s full name, and relationship to the patient.

In addition, your staff will also need the applicable CPT and diagnosis code to perform an accurate insurance eligibility verification.

2. Use online verification methods

There are various options for conducting insurance eligibility verification. However, calling the automated helpline of payers and waiting to speak to an insurance agent is an extremely cumbersome process. It should be the last option your medical billing staff must use.

We recommend that you perform the eligibility check directly through the insurance company’s website or through information portals such as Availity and Navinet. If a patient arrives at the medical office and you do not have the insurance information, your staff can use these portals to perform real-time insurance eligibility verification.

Clearing Houses also offer insurance eligibility verification, which is accessed through a built-in feature in the practice management system. The advantage is that you can link that information with appointment scheduling. For instance, the PMS can be programmed to book an appointment only once the insurance eligibility is done.

Note: Let your patients know that the insurance eligibility estimates are not a final number on the cost of service. There may be additional costs that the patient could be liable for, but that information will only come through once the claim is submitted to the payers.

3. Outsource insurance eligibility verification

If you want to save time and improve the accuracy of the process, consider outsourcing. A professional insurance eligibility verification partner will perform the following steps:

  • Check the patient’s eligibility (and obtain prior authorization before the patient visits).
  • Follow-ups for approvals through the payer’s portal.
  • Verify patient demographic information.
  • Verify coverage of benefits with the patient’s primary and secondary payers.
  • Update your practice management system with the approvals and other information received from the payer.

Outsourcing eligibility and benefits verification will minimize claim denials, lower the cost of billing and collections, and improve patient satisfaction.

PracticeForces virtual assistants can help you with patient eligibility verifications, prior authorizations, medical coding and billing, patient billing, and much more! Tailor your hiring requirements to support the unique needs of your medical practice. Starting @ as low as $1,000/month. Call us now – at (727) 202-5429


Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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