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Healthcare Insurance Eligibility Verification

Healthcare Insurance Eligibility Verification

Insurance Eligibility Verification is more critical today than ever with the advent of the Affordable Care ACT. In today’s insurance eligibility verification reality an ACA patient can have insurance one month and not pay their premiums in month 2 and 3. Qualified health plans are required to pay all claims for services rendered in the first month of the grace period (eligibility).Carriers will spend claims in the second or third months, at which point the patient must pay the provider for service already rendered or pay their insurance premium. If the patient cannot afford the payment for their premium, then any physician claims pending during this second and third month will go unpaid causing an increase in bad debt collections.


The process of obtaining the insurance eligibility verification of a patient is necessary to insure that the patient has coverage, services that are being provided are covered, denials and appeals can be minimized and payments are expedited at the appropriate rates. Denied claims due to no active coverage, out of network, unauthorized patient procedures or visits can be a major loss in revenue and should not be taken lightly.


Insurance eligibility verification process can be accomplished via a call to the Insurance Company (payer), via websites (payer or EDI) or through online software currently integrated in many medical billing systems. Through accurate Insurance Eligibility Insurance Verification, revenue cycle management can be improved by reducing the number of rejected medical claims and improving the cash flow to the Facility or Providers. There are many missed opportunities to secure payment and reduce staff time when patient insurance eligibility verification is not performed before service is rendered. It is also very important to keep your returning patient’s records up to date. Personal information such as phone number, address and insurance coverage information can change since you last saw the patient. Therefore, always verify the information on file is current and up to date.


MGSI has been offering Insurance Eligibility Verification services to its clients for more than a decade. The service is offered as part of the full revenue cycle management or as a ‘stand-alone’ service if needed. MGSI offers this service at two levels - the first level is a basic insurance eligibility verification that gets coverage details of the patient in addition to the co-pays and deductibles applicable. The second level is much more in-depth and involves the gathering of ‘code specific’ eligibility with annual max or lifetime limits and authorizations when required. Insurance eligibility verification along with benefits information before services are rendered leads to fewer claim rejections and denials, Insurance eligibility verification when leveraged with our billing and coding services will increase clean claims, improve cash flow, minimize bad debt and increase patient satisfaction.

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