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Real time eligibility is the process of determining a patient or resident’s insurance coverage in real-time through the use of software as opposed to using manual processing. It allows for more efficient and effective use of healthcare resources as well as better customer service in nursing homes.

How does real time eligibility work?

Real time eligibility is made possible through the exchange of electronic data between providers and payors. Prior to the introduction of EHRs and real time eligibility software into the long term care industry, nursing homes would collect resident information before or at the time of admission. Staff would then call the insurance provider to verify that the senior is insuranced. This manual process was not only time-consuming—taking anywhere from a few days to a few weeks to complete—but also prone to human error. 

Facilities now use real time eligibility software that has shortened the process to mere minutes. After the facility’s admission team has entered all resident information into the long term care EHR system, the software will electronically send a request to the insurance company for verification. Within minutes, the payor responds with a real time eligibility report that indicates the extent of insurance coverage for the resident and whether or not they are eligible for Medicare and Medicaid

The two methods of real time eligibility verification

There are two ways that long term care staff can perform real time eligibility verification:

Nursing home staff using real time eligibility software for resident insurance verification.
Some EHRs come with real time eligibility checks built into the system.
  • Online insurance verification portals: These are websites that enable long term care providers to check a resident’s insurance coverage. To use an online portal, SNF staff will need the patient’s or resident’s name, date of birth, social security number, and insurance plan information. This can be a cumbersome process, mainly because residents have different insurance providers, and staff may have to open multiple online portals.
  • A long term care EHR with real time eligibility capabilities: Some EHRs come with real time eligibility checks built into the system. This is by far the best option, as it means that SNF staff can input all of the resident information into the EHR, and the software will automatically send a request to the insurance company for verification. The payor will then respond with an eligibility report that indicates what the resident is covered for.

How Real-time Insurance Eligibility Verification Maximizes Reimbursement

Under the PDPM reimbursement system, long term care providers need to be especially wary of denial claims. Real-time insurance eligibility verification is one of the methods providers can use to be certain of a resident’s coverage before or at the time of admission. According to the American Association of Professional Coders (AAPC), the top three reasons a patient or resident’s claim is denied are:

  • Incomplete or incorrect resident information: If an insurance company does not have all of the correct information, they cannot verify the individual or their coverage.
  • Expired insurance coverage: If a resident’s insurance has lapsed or been canceled, the provider will not be reimbursed for services rendered.
  • Services are not covered by insurance: Some services, such as cosmetic procedures, are not typically covered by long term care insurance. If providers bill for these services, the claim will likely be denied.
MDS nurse using long term care software to conduct a real-time insurance eligibility verification check.
Real time eligibility checks are essential because they provide information such as Medicare and Medicaid health maintenance organization (HMO), type of coverage under Medicare and resident details.

Hence, real time eligibility checks are essential because they provide information such as:

  • Medicare and Medicaid health maintenance organization (HMO)
  • Type of coverage under Medicare
  • Resident details (name, date of birth, social security number, ID number, etc.)
  • Resident demographics
  • Lifetime maximum of their insurance
  • Mailing address
  • Deductible amounts and co-pays
  • Coverage dates

If a long term care facility wants to maximize PDPM reimbursements and revenue, the facility must adopt the most effective practices currently in place for real time eligibility verification. The following sequential steps will ensure that staff understand what they need to do, ensuring that nothing of importance is missed:

  • Check for inactive insurance plans and flag resident accounts that have them
  • Check the resident’s primary, secondary and tertiary insurance
  • Verify whether the resident is covered by Medicare, especially if the resident is 65 years or older
  • Confirm the services covered by the resident’s insurance policy, as well as whether a referral or prior authorization is required.
  • Ensure that resident referrals and authorizations are approved and recorded in the long term care EHR system
  • Verify whether a benefit cap is mentioned, as well as the amount of money remaining. Some insurance companies may have restrictions on the dollar value of each visit or the frequency and time frame in which treatment must be delivered.

Contact us here if you want to learn how our insurance eligibility verification technology can improve your organization’s processes.

5 Benefits of Insurance Eligibility Verification Software

Stress-free residents in a long term care facility that utilized insurance eligibility verification software.
The main benefits of real-time insurance eligibility verification software include a reduced number of denied claims, increased resident satisfaction, improved resident care, accelerated cash flows, and more time for employees.

It is now clear that insurance eligibility verification can impact the revenue of nursing homes and other long term care facilities. So what benefits does real time eligibility software give users? It streamlines the process of verifying insurance coverage by inputting the patient’s information into the system and then automatically contacting the insurance company to provide real-time results about patient eligibility.

Real time eligibility software makes it easier for nurses to understand how to check insurance eligibility, especially when accommodated by training programs for how to use the long term care software. There are five main benefits that real-time insurance eligibility verification software offers long term care facilities:

1.    A Reduced Number of Denied Claims

As we previously mentioned, one of the advantages of medical insurance verification software is the reduction of denied claims. Since all patient information is inputted into the system and the software automatically contacts the insurance company for real-time results, there is little to no chance of human error.

2.    Increased Resident Satisfaction

Another benefit of real time eligibility software is that residents report increased satisfaction levels. Residents are admitted quickly into a facility without long waiting times, and they spend less time worrying about their coverage being declined.

3.    Improved Resident Care

When staff isn’t bogged down by insurance eligibility verification paperwork, they can spend more time focused on the goal of the facility: providing exceptional care to residents. The result is a higher standard of living and more successful aging. 

4.    Accelerated Cash Flows

Cash flow is crucial for the health of any business. This holds true in long term care, where facilities that care for seniors also need to make a profit. In a facility using real time eligibility software, there are fewer claims denials.

If there are no denied claims, there are no delays in getting reimbursed from the insurance companies. This means that nursing homes can get paid for their services much quicker, improving their overall cash flow.

5.    More Time for Employees

Finally, real time eligibility software saves time for employees. Instead of having to contact insurance companies or look up patient information manually, the software does all of the work. This gives employees more time to focus on more urgent tasks.

The Importance of Real Time Eligibility Checks in Long Term Care

Real time eligibility software reduces the number of denied claims, improves resident satisfaction, and accelerates and improves cash flows. So the importance of long term care staff learning how to use this software cannot be overstated. When looking for real time insurance software for your long term care facility, be sure to find a reputable provider that offers comprehensive training programs. This will ensure your staff knows how to use the software and can take full advantage of the benefits it has to offer.

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