I-Med Claims - Medical Billing Company
patient eligibility verification

The Value Of Eligibility Verification In the RCM Process

The process of patient eligibility verification before treatment has a significant impact on revenue. Various verification options are available, each affecting payment rates from providers and patients differently. Time spent by employees in the verification process is also a crucial consideration, with manual verification being more time-consuming than electronic verification. As an RCM provider, you want to ensure that you can capture the highest possible value from your patients’ treatment costs. And you do that by having accurate eligibility data. 

The Importance of Patient Eligibility Verification in Medical Billing

Patient Eligibility Verification is crucial for medical billing. Most patients have health insurance plans that cover their medical expenses. Medical staff must confirm patient eligibility for insurance. Failure to verify eligibility can result in unpaid claims by insurance companies. According to a survey by the Medical Group Management Association (MGMA), up to 23% of insurance claims are denied due to eligibility issues. It is crucial to determine the patient’s responsibility before providing care to improve the patient experience and revenue cycle. Upfront collection of co-pays or coinsurances can increase cash flow and minimize delays in revenue collection. Healthcare providers can enhance upfront collections by knowing the patient’s responsibility.

The Significance of Insurance Verification and Pre-Certification Before Receiving Medical Services

Verifying insurance eligibility and pre-certifying medical services is essential for healthcare facilities to reduce claim denials. Experienced medical billing and coding professionals can train their staff on insurance verification processes to minimize claim denials. It is crucial to verify Medicare eligibility before a patient’s admission to reduce the chances of claim rejection. Simple errors in claim filing can lead to a claim denial, making it crucial for healthcare facilities to ensure proper insurance verification. However, today there is a growing concern regarding the rate of false positives created using RCM data during verification procedures. Businesses must know adequately about the most common fraudulent scenarios in different industries and how they can be minimized using various control measures.

According to a survey by the American Medical Association, up to 7.5% of claims are denied due to eligibility issues. 

Reasons for Claim DenialsPercentage
Eligibility issues7.5%
Coding errors5.8%
No pre-authorization4.6%
Duplicate billing4.4%
Untimely filing3.3%

Source: American Medical Association, National Health Insurer Report Card, 2019.

Benefits of Insurance Eligibility Verification for Providers and Patients

Benefits for Providers:

  • Estimation of patient responsibility for services allows for the collection of payment at the time of service
  • Gathering necessary authorizations before providing care or services
  • Promotion of higher clean claim rates by billing the correct insurance and determining billing order

Benefits for Patients:

  • Planning for financial responsibility reduces stress and worry over surprise bills
  • Opportunity to search for a lower-cost provider or insurance policy
  • Planning for services can ease uncertainty about healthcare costs

How Patient Eligibility Verification Impacts Patient Payments

Patient Payment Estimates

Verifying coverage in advance assists practices in estimating the patient’s total financial responsibility for payment. This also helps patients by providing them with an estimate of their out-of-pocket costs, allowing them to plan and prepare for the expense accordingly. Patients informed of their estimated total before appointments are more likely to come prepared to pay or make payment plans.

Confuse About the Coverage

Patients may not have accurate information about their coverage. Insurance information can be confusing and changes rapidly. Informing patients as soon as possible helps them budget for any extra costs or create a payment schedule, which can prevent surprise bills.

Helping Patients Pay Bills On Time

Verifying eligibility beforehand enables practices to assist patients in obtaining all the necessary information to avoid being caught off guard by unexpectedly large bills, as most patient’s desire to make timely payments.

Protecting Practices

Conducting eligibility verification beforehand can serve as a protective measure for practices in cases where insurance coverage has expired or policies do not encompass the services offered. It minimizes the risk of denied claims, which can cause significant financial losses for the practice.

Patient eligibility verification is critical to estimating patient responsibility for payment, reducing surprise bills, and protecting practices from denied claims.

Methods for Verifying Patient Eligibility and Its Impact on Employee Time

Various options are available to verify patient eligibility, including manual verification, electronic verification through carrier portals, clearinghouse systems, and outsourcing. Manual verification involves an employee calling the carrier to check all the information provided by the patient, which can be time-consuming and costly. Electronic patient verification methods, such as carrier portals, offer a faster and more efficient approach to eligibility verification.

Carrier Portals

Insurance carriers each have web portals that employees can use to verify patients’ coverage information. However, this process can be time-consuming and requires learning multiple platforms.

Clearinghouse Systems

Practices can enrol in a clearinghouse system that allows them to check eligibility for patients with various insurance carriers in one location. This saves time and effort because employees don’t need to learn multiple systems to complete the task.


Outsourcing patient eligibility verification to an experienced outside agency is optimal because it frees up employees from clerical work and increases efficiency. It is beneficial when there is a high volume of patients and limited employee resources.

Verifying patient eligibility before services is essential to ensure seamless revenue cycle management. Choosing the best option that suits the practice’s needs can help save time and money while providing the accuracy of patient information.

The Need For Eligibility Verification In the Revenue Cycle Management Process 

The importance of eligibility verification in the healthcare industry cannot be overstated. It is crucial in ensuring a smooth and efficient revenue cycle management (RCM) process for medical practices.

Reduced Denials and Enhanced Reimbursements

Insurance companies work closely with patients to verify their eligibility and benefits, reducing the number of claim denials and increasing reimbursements for medical services.

Clean Claims

Accurate patient information obtained during eligibility verification ensures error-free claims submission, higher collections, improved patient satisfaction, and a better overall experience.

Enhanced Cash Flow

A streamlined RCM workflow that includes eligibility verification results in increased cash flow for medical practices by reducing the number of unpaid claims and improving overall revenue streams.

Improved Workflow

The verification process helps to streamline information, improving the workflow of the entire RCM process. It can lead to a more efficient and satisfactory patient experience.

Improved Self-Pay Revenue

Eligibility verification leads to a rise in self-pay revenue as patients are assisted with unknown coverage and provided with online coverage verification, resulting in streamlined payment processes and improved self-pay revenue.

Eligibility verification is critical in RCM processes, resulting in improved financial outcomes, smoother workflow, and enhanced patient experience. Medical practices should prioritize eligibility verification to ensure the success and sustainability of their operations.

Ways To Strengthen Patient Eligibility Check Process In RCM

Adequate patient eligibility verification is crucial for the smooth functioning of healthcare practices. Here are some key ways to strengthen the patient eligibility check process:

Audit and Train:

Start by auditing the current process for patient eligibility verification. Identify inefficiencies and provide regular training to staff to maintain effective checks on the process.

Leverage Technology:

Use cloud-based software that provides real-time patient coverage information and claim status automation software that fetches the real-time status of submitted claims. A professional Revenue Cycle Management outsourcing company can assist with the overall process.

Measure, Monitor and Analyze:

Continuously measure and monitor your denial rate and use analytics to gain insights into which claims are at high risk of denial. This helps to minimize denials and avoid the costly process of appeals.

By implementing these steps, healthcare practices can streamline their eligibility verification process, reduce denials, and improve their revenue cycle management.

Eligibility Verification Process At I-Med Claims 

The Patient Eligibility Verification process at I-Med Claims includes the following:

Patient Scheduling:

I-Med Claims receives patient schedules via EDI, email, or fax or checks them daily in the appointment scheduling software.

Insurance Coverage Verification:

We verify patients’ insurance coverage with primary and secondary payers by calling the payers and checking through their authorized online insurance portals. In case additional information is required, they contact patients.

Updating Medical Billing System:

The eligibility and verification details such as member ID, group ID, coverage period, co-pay, Deductible, and coinsurance information are updated in the medical billing system along with other code-level benefits information, including max limits allowed.

Immediate Issue Resolution:

In case of any issues regarding a patient’s eligibility, we inform the client immediately for prompt resolution.

Thorough Verification:

I-Med Claims’ dedicated insurance eligibility verification team delivers a thorough verification process, which aids in the dramatic reduction of clients’ accounts receivable cycle.

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