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Insurance eligibility verification is the process by which healthcare providers verify a patient’s insurance status. Healthcare providers must ensure a patient’s eligibility, as it directly impacts Accounts Receivable billing (AR), denial claims, and payment delays. All of these play a vital role in a healthcare provider’s revenue cycle and determine the financial success of the healthcare provider. 

Hospital nurse confirming a patient's insurance eligibility verification.
Hospital nurse confirming a patient’s insurance eligibility verification.

A patient’s insurance status can be categorized into several claim statuses, such as submitted, received, pending, accepted, and rejected. Some of the most common reasons for denial of patient claims include:

Get Insurance Authorization: If a long term care facility wants to provide non-emergency medical services to a resident, they should look into pre-authorization services from the insurance payor prior to delivery of the service. Also, during the pre-admission process, a long term care facility’s billing team should first get approval from the insurance payor before administering any procedures or services. 

Check the Authenticity of the Claim to verify whether a patient’s insurance coverage is active: If a facility does not verify a patient’s eligibility status before administering care, they risk not being paid for the services they provided. 

Even though these pre-admission steps may be considered tedious and time-consuming, they are necessary for the facility, as they ensure correct payment is received for services rendered to patients and residents. 

Find the Relevant EVS: It can be confusing for long term care facilities to understand the insurance eligibility verification process, mainly because each state has a different Eligibility Verification System (EVS). The EVS enables long term care facilities and other healthcare providers to access patients’ eligibility information within a specific time period. 

For example, in Massachusetts, healthcare providers must adhere to the MassHealth policy and make insurance eligibility claims through the Provider Online Service Center (POSC). The POSC allows for batch verification submissions while still processing transactions correctly and efficiently. Meanwhile, in Oklahoma, healthcare providers can call a national toll-free number to obtain patients’ eligibility information and make claims inquiries. 

Regardless of the state and their procedures, healthcare providers must check a patient’s EVS for each service, as patients have different insurance coverage and their coverage can change with time. EVS data is also made available around the clock so that healthcare providers can submit insurance claims in bulk or one at a time. 

How to Use an Insurance Verification Training Manual to Support Insurance Eligibility

Because the insurance eligibility verification process can be complicated, long term care facilities should have an insurance verification training manual to help staff learn the insurance eligibility verification process. This helps nursing home staff better understand the health insurance process and how it impacts patient care and the payment process. 

Long term care facilities must offer sufficient training in the insurance eligibility verification process because patients may not fully understand their insurance policies. In such cases, the facility’s staff will need to explain the procedures when they are asked insurance-related questions. Therefore, if a facility creates a good payment culture, there will be fewer payment issues and conflicts. These processes can be facilitated by using a long term care software system that includes online training programs.  

A typical insurance verification training manual will include information on verification training, eligibility in the revenue cycle, information on members’ cards, and the facility’s medical billing process. Some state manuals may also include templates and examples on verifying eligibility and co-payment so staff can complete the insurance eligibility verification process accurately.

To ensure Medicare eligibility, healthcare providers and long term care facilities must use the HIPAA Eligibility Transaction System (HETS), which grants access to eligibility data for Medicare providers, suppliers, and authorized billing agents. The eligibility data will then create the Medicare claims, highlighting the eligibility for specific services or beneficiary liabilities. 

The CMS ensures that HETS has a high system performance in several ways. For example, they notify healthcare providers when the systems are down, provide a support help desk, and monitor contractors’ performances. These combined services allow CMS to identify weaknesses in the system to adapt and make technical improvements. 

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5 Steps for Eligibility Checks

Most long term care billing teams will first use eligibility checks to investigate the eligibility of insurance claims. As mentioned earlier, insurance eligibility verification determines if a patient is eligible for insurance payments under their insurance payment plan. In such cases, a long term care facility must verify the resident’s eligibility status before administering any care. 

Meanwhile, the Verification of Benefits identifies what the insurance payors cover for individual services, which allows facilities to estimate the total resident costs and the exact amount the insurance payor will cover and payout. It is worth noting, though, that each insurance payor covers different services. Hence, it is essential to verify what services are covered under the resident’s member plan before services are rendered. 

It is also essential for facilities to understand eligibility claims and obtain the correct patient insurance information. One should note that problems can occur when patients are covered by their employer’s insurance plan. This is because the patient usually does not know all the details of what services are covered by their insurance plan, creating the need to verify insurance eligibility.

When a facility’s billing team performs eligibility checks, they follow a standardized process to ensure they obtain the correct insurance information. The following five steps, as outlined by revenuexl, are used to check a patient’s insurance eligibility

Step 1 – Collect the Patient’s Insurance Information

The billing team needs to ask appropriate questions during insurance eligibility verification to collect the relevant information, such as:

A doctor shows a patient the hospital's insurance verification training manual.
Facilities must adhere to the hospital’s insurance verification training manual.
  • Patient’s name, date of birth, address, and social security number
  • Insurance payor, insurance payor’s telephone number, and the patient’s insurance member ID number 
  • Any authorization that is required
  • Referrals that are required 
  • Any relevant deductibles 
  • Claims submission address
  • In or out of network details

Collecting the relevant insurance information can be time-consuming, especially if a patient has multiple insurance policies. In such cases, the billing team will need to gather the relevant information for each insurance policy. Once the insurance information is collected, it needs to be recorded in the facility’s long term care software system. 

Step 2 – Make a Copy of the Patient’s Insurance Card

This gives the facility an electronic copy of the patient’s insurance information, which can be entered into the long term care EHR. Should there be any typing errors in the insurance information, the copy can serve as a backup used to correct the information on record. Staff can also use this information to double-check the patient’s insurance ID numbers before submitting a claim.

Step 3 – Contact the Insurance Payor

Even though a patient may have presented an insurance card initially, insurance coverages can change or be discontinued. Therefore, facilities need to contact the insurance payor to verify the patient’s current eligibility status. Obtaining accurate insurance information and updating it in the long term care software system is essential, as it allows the billing team to call the insurance payor and verify the insurance claim. 

Step 4 – Ensure Resident Information is Accurate 

Facilities need to train their billing staff to be meticulous when transcribing and recording resident information. Lots of information needs to be collected to file an accurate insurance claim, and a single error can result in a claim denial or cause delays in payments. These delays will have a negative impact on a facility’s revenue cycle. For this reason, it is of utmost importance for the facility to provide staff with clear guidelines in the insurance verification training manual. Some long term care software systems will also have tools to streamline their insurance verification policy and procedures, thus saving your team time and helping them stay in compliance with regulations. 

Step 5 – Follow Up With Residents When Necessary

Should a facility be concerned about a resident’s insurance information, they need to obtain more information about the patient’s eligibility status. Facilities can search online about the insurance payer’s eligibility-checking resources or use the resident’s “member services” or “provider portal” to gather more information. In such cases, it is wise to inform the patient as soon as possible. They must know that, if the insurance information is not obtained, there is a chance that they will need to cover the expense themselves. 

How Long Term Care Software Facilitates Insurance Eligibility Verification

While it may be impossible to completely eliminate claim denials, long term care facilities can reduce their number by implementing an effective long term care software system that assists and supports the insurance eligibility verification claims process. 

A facility's billing team investigates the eligibility checks of a patient's insurance claims.
A facility’s billing team will first use eligibility checks to investigate the eligibility of insurance claims.

The most advanced long term care EHR systems have a 270/271 interface with built-in AR billing functions that send and receive electronic messages about a resident’s eligibility to payers, including Medicare, Medicaid, and commercial insurance payors. This allows staff to quickly check on the eligibility of residents.

Long term care software can also streamline processes with automotive tools that alert facility staff when a claim verification needs a follow-up. This is especially important, as it gives them the information they need to track resident data more efficiently and follow up on pending claims. 

Lastly, long term care software can help track resident insurance data, which changes over time and must be updated regularly to ensure the insurance verification eligibility is correct. Failure to do so will impact the facility’s revenue cycle, consequently impacting the level of care. Using efficient nursing home software will speed up the process of maintaining accurate resident records. 

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Cindy Wong
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