Taking a Closer look at the Insurance Verification Process

From the Field

Recently I was on a call with an individual who is working on starting up a practice that focuses on servicing patients who are residents of skilled nursing facilities (SNFs), nursing homes, and assisted living facilities (ALFs). We discussed one of the biggest hurdles of providing care to patients in this setting— obtaining complete and accurate insurance coverage information for the patients. In a SNF, this can be especially challenging because when a patient runs out of covered days for SNF stays, the secondary insurance becomes primary for the patient’s stay at the SNF. In this scenario, all other services the patient receives would likely be covered under their primary insurance. This coverage scenario is most commonly encountered in a very specific setting. However, in every setting where patients receive medical care, complete and accurate insurance verification is a critical piece of the revenue puzzle.

In addition to the setting of care playing a role in complicating a patient’s insurance verification, the insurance market a practice operates in also plays a role. States like Texas, California and New York have incredibly complex markets that contain not only many regional insurance carriers but also many independent physician associations, further complicating insurance verification and the revenue cycle.

Components of a Good Insurance Verification Process

In most care settings and insurance markets, a solid insurance verification process will go a long way toward increasing collections and reducing bad debt. To build a solid insurance verification process, it’s helpful to know which payers have special requirements such as authorizations or referrals from the patient’s primary care physician. Identifying the payers that have special coverage requirements and which payers simply require a patient has active coverage will save a significant amount of time during the verification process.

Performing a detailed insurance verification can take anywhere from a few minutes to an hour or more, depending on insurance company hold times. For payers that have special coverage requirements, the company I work for typically performs the eligibility verification over the phone so we can be sure to obtain all the detail we need that is specific not only to the patient’s plan but also the provider’s network participation status. This level of detail is often difficult to obtain from an automated, online eligibility verification.

The timing of an insurance verification is also important to this process. In the event that a patient’s insurance requires an authorization or referral, it’s helpful to perform the insurance verification far enough in advance of the patient’s scheduled appointment in order to obtain the referral or authorization. Another item to consider is that some insurance markets allow patients to change Medicaid-managed care plans on a monthly basis. If a patient schedules an appointment with your office on the second of the month and you verified their insurance coverage on the 25th of the previous month, it might be a good idea to do an online verification to make sure the patient is still covered with the same plan you verified eligibility with initially.

Maintaining well-organized records of insurance verifications and copies of patient insurance cards when they are available can be incredibly helpful. On occasion, my company has encountered scenarios where a patient’s coverage is terminated retroactively, and the insurance verification documents play a role in filing timely appeals to the replacement payer.

Performing appropriately detailed insurance verifications when utilizing efficient time frames as they relate to a patient’s appointment and insurance company requirements and keeping well-organized records are the building blocks of a solid insurance verification process. It is equally important to identify the individuals in the office who are responsible for performing the verifications and the checks and balances that will be maintained to ensure the verifications are performed for each patient. Additionally, each staff member in the practice whose role is impacted by a patient’s insurance coverage—front desk, appointment schedulers, billing staff, and credentialing staff—should be familiar with the entire process so they can obtain the information regarding a patient’s insurance coverage they need to perform their role.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome, and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.