What is Eligibility and Benefits Verification?


To receive payments for the services rendered, healthcare providers need to verify each patient’s eligibility and benefits before the patient’s visit. Some estimates indicate that as many as 75% of the claims getting denied are on account of the patient not being eligible for the services rendered by the healthcare provider. Unfortunately, it is one of the most neglected processes in the revenue cycle chain.


IMPACT OF INEFFECTIVE ELIGIBILITY/BENEFITS VERIFICATION AND PRIOR AUTHORIZATION PROCESSES


Ineffective eligibility and benefits verification and/or prior authorization processes can result in increased claim denials, delayed payments, additional effort on rework, delays in patient access to care, decreased patient satisfaction, and non-payment of claims.


OUR SERVICES


Linus brings you a team of experts to help you accelerate your client’s accounts receivable cycle. We confirm the patient’s eligibility and obtain necessary prior authorization before the patient visits the physician’s office.

Our team members will do the following as a part of the verification processes:


  • Receive patient schedule from the healthcare provider’s office – hospital and/or clinic
  • Perform entry of patient demographic information
  • Verify coverage of benefits with the patient’s primary and secondary payers:
  •                            Coverage – whether the patient has valid coverage on the date of service
  •                            Benefit options – patient responsibility for copays, coinsurance, and deductibles
  • Where required, the team will initiate prior authorization requests and obtain approval for the treatment
  • Update the hospital’s revenue cycle system or the patient’s practice management system with the details obtained from the payers.


Patient Demographics Entry (Patient Registration) Services


Accurate capture of patient details is perhaps one of the most under-rated processes in the revenue cycle process chain. Not only does the data captured in the demographic entry process form the base for the medical record, but it also affects insurance claims payment. Error-free capture of patient information is essential for clean claim submission and facilitates quick claims processing by Payers. 

The front-office at the place of service should accurately capture the patient information, either via paper-based registration processes or via the scheduling system. Accurate information about the patient is critical to ascertain the patient's eligibility and benefits, obtaining prior authorization, and error-free claims filing. Additionally, population health analytics is possible only by utilizing accurate patient information. 


  • Patient's legal name, age, gender, address, phone numbers

  • Patient's social security number for dentification

  • Payer information (name of the Payer, mailing address for claims, and group and policy numbers)

  • Details of secondary as well as primary Payers

  • Medicaid or Medicare card (if the patient receives federal or state assistance)

  • Allergies if any

  • Special requirements (interpreter, assistance for physically disabled people, medications, Ambulance, stretcher access, etc.)
  • Name, address, and telephone number of the person who will be responsible for payments.

IMPACT OF INACCURATE CAPTURE OF PATIENT INFORMATION


Inaccurate capture of the Patient information could result in:


  • Increased claim denials and delayed payments. Incorrect details captured cause rework as the clearinghouse systems, and the payer claims adjudication platforms may reject the claims. As a result, delays in obtaining payment or losses on account of unpaid claims can occur.
  • Inaccuracies in Population Health Analytics. Identification of the right population segments based on demographics data is the anchor for Population health analytics