Verification & Prior Authorization for Health Plan Coverage

With rising labor cost and decreasing insurance reimbursement, practices cannot afford to lose money on unpaid claims. A major safeguard to successful Revenue Cycle Management (RCM) is accurate insurance coverage verification. In order to do accurate coverage verification, the following guidelines are very helpful.

Verification of insurance benefits is one of the most important parts of the billing cycle. It needs to be done before patient receives treatment. In today’s ever changing health care environment, a thorough understanding of Insurance verification process is the key to successful billing.

Scheduling Appointments

Patient care starts with the first phone call received by the doctor’s office. During creation of appointment, care must be taken to ensure correct spelling of patient’s name, correct date of birth, contact information, and detailed insurance information. Any incorrect information at the time of scheduling will lead to incorrect verification and claim rejection. It is a good practice to get two or more phone numbers, in case patient cannot be contacted. We recommend getting patient’s email address and emergency contact number as well.

Coverage Verification

This is the most time-consuming part of the billing process. Incorrect verification is directly linked with higher claim rejections. Verification can be done through provider's clearing house, insurance portals, and also by directly calling insurances. When there is any doubt with online or automated information, we always call insurance for clarification. At the time of verification, the minimum information needed is Co-Pay, Co-Insurance, Deductible, and Out-of-Pocket maximum. Also required is Referral information and Pre-Authorization information for procedures and tests.

Insurance Verification by FCbilling

Our highly trained and dedicated verification team is your practice’s safeguard to claim denials, costly write-offs, and high insurance outstanding. In addition to health coverage verification, our services includes referral review, prior-authorization, and pre-determination services as well.

We document verification details directly into practice software with information such as insurance portal findings, call reference numbers, referrals, authorizations, co-pays, co-insurance, and all other needed details. We complete coverage verification before patients come in to see the doctor to facilitate smooth patient processing. Well-informed staff and well-informed patients are a formula for success.

Benefits of Insurance Verification

Efficient eligibility verification is a tool for increasing practice earning.

i. Increase Revenue

Error free verification means correct information on the claim (referred to as a Clean Claim). Clean Claims get processed faster ensuring quick payments from insurances. Any balance owed by patients can also be recovered faster when bills are sent to patients closer to the service date.

ii. Minimize Non-Pays

Verifying Insurance before visit date results in fewer claim rejections. Not verifying coverage might result in a high number of rejected claims and high accounts receivable. Being able to stay ahead of payment obstacles will result in less billing mistakes, claim rejections, and reimbursements delays.

iii. Identify Insurance Requirement

Verification team will submit information to insurance about services likely to be performed during the visit. Insurance will then be able to give feedback on any requirement for referral or authorization. During this process, a check will be done for the provider to confirm in-network status.

iv. Increase Patient Satisfaction

In a survey conducted by InstaMed, a J.P. Morgan company, 9 out of 10 patients wanted to know about their responsibilities in advance. No one likes surprise billing for treatments. If a test or procedure is not covered by insurance or if the provider is out of network, the patient will end up with the burden of paying a large bill. This will surely result in patient frustration and dissatisfaction with the practice. Situations like these are not only bad for patients but also damaging to the practice’s reputation.

Why Do Insurances Require Prior Authorization?

There are many different insurance and health plans available in each state and new ones are coming in the market frequently, all with different levels of benefits. Medical offices need to determine the type of insurance a patient has and the coverage it offers. Good understandings of coverage will aide providers in creating treatment plans with minimum burden to patients. It is important to keep patients in the loop as well, in order to keep them informed about their health coverage. Treating patients without verification of coverage might result in claim denial or unexpected medical costs transferred to patients.

Our Distinct Pre-Authorization Service

Our Pre-Authorization team helps doctors obtain insurance approval for medical services, drugs, or durable goods before servicing patients. Each insurance plan has its own pre-authorization policy. The determination for need of pre-authorization has to be made at the time of verification. If services are provided to patients without obtaining required authorization, claims will be denied and clinics will not be allowed to bill patients.

Importance of obtaining pre-authorization – Even though pre-authorization is not a guarantee of payment, claims are confirmed not to get paid if required pre-authorization is missing.

1. Information Needed to Obtain Pre-Authorization

Billers will need correct patient information, scheduled service date, place of service, service codes, and diagnosis codes to give to the insurance representative. They will also need to make note of the date and time of the call with representatives and obtain a call reference number. It is a good idea to keep a hard copy of the approval letter and also scan a copy into the patient’s file.

2. Pre-Authorization and Claim Payment

Once the authorization is obtained, call insurance back to verify the allowed fee for the service, any co-pays, co-insurance, or deductible amount which will be patient’s responsibility. It is always a good idea to collect this amount from patients before services are rendered.

3. Keep Patients in the Loop

The Pre–Authorization process can be complicated and take several days to several weeks. It is always a good idea to keep patients informed on the status. Sometimes it is also helpful to have patients call insurance to inquire if they can supply any needed information. If there are any issues of pre-existing condition, a call from the patient will definitely help. If patients are kept well informed, clinics can avoid patient frustration and provide services more efficiently.

4. Work Smarter Not Harder

Use technology to your benefit any time you can. Billers should create insurance portal accounts for all major insurances. Often pre-authorization can be done quicker through portals. Biller can easily upload all medical records, test results, x-rays, and photos through portals. Mailing forms and medical records is a very slow process and faxes may not reach the right department or person. Insurance portals are easy to use, they are HIPAA compliant, and clinic is able to see status updates at all times.

Benefits of working with FCbilling

Healthcare professionals at FCbilling are well-versed in billing and coding. They are able to tackle all issues related to revenue cycle management.

Our claim submission process includes exam review, claim scrubbing, and ensuring proper coding of services. Our goal is to submit error free claims and bring in payments with first claim submission.

Our correct claim submission rate is 99%. Compliance safeguard is built into our billing and coding process. Our efficient billing and coding reduces refund requests and audits. We are always ready to give feedback to our providers, work with insurance on their behalf, and work with practice staff to complete the billing cycle efficiently.

Which Services Require Pre-Authorization

Each insurance plan is unique in its requirement for service coverage. Unless the practice is absolutely certain that pre-authorization is not required, such as traditional Medicare, biller should confirm with insurance for all high-value services. Common services which might require pre-authorization are:

Highlight of FCbilling Verification Service

FC Billing Verification and Pre-Authorization team can take care of patient processing needs for your practice. Our services are:

We are always available to answer any questions

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Don’t let your practice be lost in the maze of claim rejections, non-pays, EOBs, and LCDs. Put an end to the insurance chase. Team up with our experts for outsourcing your medical billing.