Verification of Patient Insurance Coverage

Why is this important, how does it affect the daily job of the medical biller, and how do you do it?

The majority of patients that come into the medical office have medical insurance. That means that they may have to pay a small portion of their medical bills, while their health insurance pays for the rest.


Why is verifying insurance important?

Verifying patient insurance coverage

Medical insurance will only pay for a patient's medical services if it is active. This means that the patient has paid their periodic premium for coverage, and has added all necessary dependents on the policy. This ensures that their medical bills will be paid.

If the patient doesn't have active insurance coverage, then their health insurance won't pay their medical bills, no matter what.

This means that verification of patient insurance coverage is extremely important. If a patient's coverage is not active, then you have to collect from the patient when they come into the office.

Each patient's insurance needs to be verified each time they come into the office. Although it takes time, it is one of the most important responsibilities of the medical office staff.


Who verifies patient insurance?

Luckily, medical billers typically don't have to do the verifying. Usually when a patient calls the office to make an appointment, the front office staff, such as the receptionist or scheduler, will be the one who pulls the patient medical record and prepares it for the office visit.

This includes putting any necessary papers into the chart, preparing any forms that the patient needs to fill out, and verifying the patient's insurance coverage.

Usually the health insurance is verified before the patient even comes into the office in order to save time when the patient gets there. This reduces wait time by having everything ready for the patient when he or she comes into the office.


What does "Active" mean?

When a health insurance is "active" it means that the patient, or their dependent, is currently covered by the insurance policy. This means that your office can bill the health insurance for medically necessary services and they will be paid by the insurance company.

If the health insurance is not active, for example, if the policy was cancelled due to lack of premium payment, then the insurance company will not even process the claim, much less pay it.


How does verification of benefits affect the medical biller?

Fortunately, because the front office staff actually does the verifying, medical billers rarely have to spend their time verifying patient coverage.

Unfortunately, because medical billers don't always do the verifying, they have to rely on the front office staff to make them aware of any important changes with a patient's insurance. This means that sometimes claims get sent to the wrong insurance company, or they are denied due to lack of coverage, because they are inactive.

This also means that a very important part of the job of a medical biller is to communicate with the front office staff, or whoever does the insurance verification, and make sure that there is an effective way to update patient insurance information, make any important changes with the patient's insurance, and make sure all claims are sent to the right insurance carrier.


How do you verify insurance coverage?

One of the responsibilities of insurance companies is to identify their patients and provide a way for medical offices to verify patient insurance coverage. This means that you will never be without a way to verify insurance for your patients, unless it is after hours or on the weekend.

There are two main ways to verify coverage:

Over the phone: The most time-consuming way to verify patient insurance coverage is over the phone.

Located on each and every insurance card is a contact phone number for the insurance company. Sometimes there are numerous numbers, including numbers for departments like hospital admissions, referrals and pre-authorizations, member services, and provider services.

Because you are calling from a provider's office, when you call an insurance company you should always call the provider services number, or the main phone number and ask for provider services.

Once you call the provider services line, you will need a few things in order to verify that you are calling from a real provider's office. This proves to the insurance operator that you are calling from a verified doctor's office so they can release information to you.

If the insurance company simply released information to you without verifying who you are, it would be a breach of HIPAA confidentiality.

After this, you will need a few more things to identify the patient, so the operator can determine their coverage. You typically need the patient's name, ID number, and date of birth. These three things will help the operator locate your patient.

Once your patient is located, the operator can tell you if the patient has active coverage, and the amount of the copay, coinsurance, or deductible amounts.

Online: An easier way to verify patient insurance coverage is online, although it is not always free and some insurance companies do not have an online verification option. Depending on your office, you may be able to verify patient insurance through an online clearinghouse, such as Availity.

This clearinghouse allows you to check patient coverage for a number of different insurance companies. All you have to do is log into the site, enter the patient's information, and hit the enter button. The patient's insurance information will display on the screen, allowing you to select the type of benefits you want to verify so you can make sure the patient has active coverage.

Some insurance companies have their own websites, which have coverage verification capabilities directly on the site. These typically work in the same way.

One important thing to remember about online verification is that you will need to either subscribe to the clearinghouse or be a contracted provider with the insurance company. This allows you access to the site and provider information. If you are not a contracted provider or if you are not subscribed to the site, you will have to call to verify patient coverage information.


After you verify coverage...

After you verify that your patient is covered, you check the copay, coinsurance, or deductible amounts, so that you can collect the right amount while the patient is in the office. For more information on how to verify specific benefits and what this means, see our article on verification of benefits.

Now you know that your claim will be paid and the patient's financial responsibility will be filled, you can allow the patient to go back and see the doctor!




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