Importance of Insurance Eligibility Verification

insurance eligibility verification

A review as it relates to denials or delays in payments of a practice’s A/R (account receivables) may result in findings that insurance eligibility-verification is not being done correctly or at all by the office staff.  Today’s healthcare environment has produced confusion on insurance plans not only to physician practices, but to patient’s with the plan.  Many of the affected patients are unfamiliar with how healthcare insurance works or those with low cost premiums results in a higher deductible or coinsurance.  As a result your patient account receivables begin to escalate rapidly or the frequency of denials increases as well.  Insurance eligibility-verification is critical in today’s healthcare environment and must be performed before the patient is actually seen by the physician in order to reduce the probability of services being denied for payment.

MGSI’s Practice management software allows the physician’s office staff to obtain real-time insurance eligibility verification.  In addition, many payers have options to check patient eligibility on their website. Insurance verification not only will confirm if the patient has coverage, but what the patient’s deductible is, how much has been met, and even if the patient’s policy may be suspended due to lack of premium payments. Having an experienced team to also verify if a certain procedure (in office or in a facility) is covered under the patient’s plan or if authorization is required is essential.

If you are not verifying benefits electronically- do you have use an insurance verification form?  Is your staff trained in the right questions to ask when calling payers?

Physician offices often make the mistake of not having sufficient staff to accomplish these daily tasks to insure the physician will be reimbursed for services that will be rendered or performed.  Many times the staff in the offices that have the responsibility for insurance-eligibility has so many other tasks they are responsible for which makes it difficult if not impossible for them to handle this daily task as the daily practice environment can be hectic. Some of these other tasks are , to name a few:  checking in patients, check out, answering phones, handling referrals, filling in for staff who are out sick or on vacation, etc., therefore, not having dedicated time to verify insurance eligibility prior to the patient coming into the office.

When requesting or obtaining a referral from a payer, physician office staff often time do not obtain the correct referral for the correct service (CPT code) which will be performed.  We often see referrals coming in with charges where the referral obtained is completely unrelated to the service rendered, therefore, causing an expected immediate denial of the claim.

Collaborating with an outside medical billing company to provide insurance eligibility verification for your practice will result in insuring that physician services, procedures performed in the office will have a positive financial result to the physician.

About MGSI:

As a national medical billing company based in Tampa, Florida since 1992, MGSI can provide you with insurance eligibility services.  For more details, please visit