Verifying Insurance Coverage

How to verify a Patient's Insurance Coverage

Verifying a patient's insurance coverage can be challenging. With hundreds of different plans and dozens of companies with multiple portals, checking your patient's insurance plan details can be a time-consuming, tedious task.

To check a patient's insurance network, you must gather their insurance information, verify the details with their insurance carrier, check their network eligibility with your provider's NPI number, and review the details for any exclusions, exceptions, and other rules. Then after all of this, you may need to start the "pre-authorization" process for more involved procedures. Needless to say, checking insurance can be time-consuming but we've put together this guide with some tips and tricks on what's involved in verifying a patient's insurance coverage & how to make it easier. 

Gathering Insurance Information

The first step in verifying coverage for any patient is having a method for collecting the patient's insurance card and any other relevant information, such as the policy number and the name of the insurance company. There are a few ways to do this and every practice is different so we recommend you use whatever works best for you. If you don't have a simple way of getting your patient's information today, you can reach out to us by filling out our contact form here we would be happy to help you set one up for free! 

You can ask the patient to bring their insurance card. Request that the patient bring their insurance card with them to their appointment. This is typically the most accurate and up-to-date source of insurance information.

You can also use a patient intake form. Have the patient fill out a patient intake form that includes their insurance information. This can help ensure that you have all of the necessary information and can also serve as a record of the information for your records.

Verify the information. It's important to verify the information that the patient provides to ensure that it is accurate and up-to-date. You can do this by contacting the insurance company directly or using an online verification tool.

Keep the information secure. It's important to protect the patient's personal and insurance information from unauthorized access. This includes properly storing paper records and using secure electronic systems for storing and transmitting the information.

Contacting the Insurance Company

You can then verify a patient's insurance by contacting the insurance company directly. Some insurance companies have online portals or automated phone systems that you can use to verify coverage. These are a few of the options you can use to verify insurance:

Call the customer service number. Most insurance companies have a customer service number that you can call to speak with a representative. You can typically find this number on the back of the patient's insurance card or the insurance company's website.

Use an online portal. Many insurance companies have an online portal that you can use to access information about a patient's policy and coverage. You may need to create an account and log in to access this information.

Send a letter or fax. Some insurance companies may prefer to communicate through traditional mail or fax. You can send a letter or fax to the insurance company to request information about a patient's policy and coverage.

Use a third-party verification service. There are also third-party services that can help you verify a patient's insurance information. These services typically charge a fee for their services and may require you to provide certain information to access the information you need.

Contacting the insurance company to verify information can take a bit of time depending on the carrier's portal, hours of operations, and staffing availability. Be sure to put enough time into your process to verify patients' insurance coverage before their visit to prevent any complications. 

Checking Coverage and Eligibility

Verify that the patient's policy covers the services you will be providing, and check to see if the patient is eligible for coverage to prevent any surprise costs and ensure you and your provider get reimbursed. To check eligibility you can:

Contact the insurance company: You can call the insurance company or use an online portal to check for coverage and eligibility. You may need to provide the patient's policy number and other identifying information to access this information.

Use a third-party verification service: There are also third-party services that can help you verify coverage and eligibility. These services typically charge a fee for their services and may require you to provide certain information to access the information you need.

Use an electronic health record system: If your practice uses an electronic health record (EHR) system, you may be able to access coverage and eligibility information through the system. This can save time and help ensure that you have accurate and up-to-date information.

Ultimately, the easiest way to check for coverage and eligibility will depend on your specific circumstances and the resources available to you. By using one of the options listed above, you can quickly and efficiently check for coverage and eligibility to help you provide the best possible care to your patients.

Check for any restrictions or exclusions

Find out if there are any restrictions or exclusions on the patient's policy that may affect your ability to provide care.

Use a third-party verification service. There are also third-party services that can help you verify coverage and eligibility, including any restrictions or exclusions. These services typically charge a fee for their services and may require you to provide certain information to access the information you need but can save you tons of time. They are often up to date with any payer updates and changes and will automatically use the most current ruleset to verify your patient's details. 

Check the patient's policy documents. The patient may have a copy of their policy documents that outline any restrictions or exclusions. You can ask the patient to provide these documents or ask the insurance company to send you a copy.

Obtain pre-authorization

If necessary, obtain pre-authorization for any services that require it. This helps ensure that the insurance company will cover the costs of the services. By following these steps, you can help ensure that the insurance company will cover the costs of the services or procedures you are planning to provide. This can help you provide the best possible care to your patients while also avoiding potential billing issues.

First, determine if pre-authorization is required. You can check the patient's insurance policy or contact the insurance company to determine if pre-authorization is required for the specific service or procedure you are planning to provide. This is usually done by reviewing the specific plan details or calling the insurance company and asking them for details on the diagnosis, procedure, and how it falls into the plan's details. 

Next, you will want to begin gathering all relevant information. You will typically need to provide certain information to the insurance company to obtain pre-authorization. This may include the patient's policy number, the specific service or procedure being requested, and any relevant medical records or documentation.

Submit a pre-authorization request: You can submit a pre-authorization request to the insurance company through their website, by phone, or by fax. Some insurance companies may have specific forms that need to be completed and submitted.

Wait for a response: The insurance company will review the pre-authorization request and respond. This process can take some time, so it's a good idea to submit the request as far in advance as possible.

Summary

Verifying a patient's insurance coverage can be challenging. With hundreds of different plans and dozens of companies, you must gather their insurance information, verify the details with their insurance carrier, check their network eligibility with your provider's NPI number, and review the details for any exclusions, exceptions, and other rules.

This is why many practices have turned to technology to help them service all of the patients they see to ensure they are verified and eligible for the care they are scheduled to receive. Today, EHR companies have partnered and or built solutions to help their customers do this faster and with greater accuracy.

If you are not sure your EHR can verify your patient's insurance details, our team would be more than happy to tell you more about your current EHR and its capabilities or limitations. Please feel free to reach out to us for a Complimentary EHR Review by filling out our contact form here.