How to Verify Patient Healthcare Insurance

What is insurance verification?

Insurance verification is the process of confirming a patient’s insurance coverage and benefits before an encounter. More importantly, it confirms that a patient’s insurance plan covers the services you provide and is in your network. If not, you can either block the patient from seeing you or inform them that they’ll have to pay entirely out of pocket for your services.

The health insurance verification process

To verify a patient’s health insurance, take the following steps:

1. Collect patient insurance information during intake and registration.

When was the last time you saw a patient intake or registration form without an area for the patient’s insurance information? When was the last time you heard an appointment-scheduling call during which the patient wasn’t asked for their insurance info? You probably can’t think of the answer to either question, or maybe it’s simply never. There’s a reason for that. With a patient’s insurance information immediately available, your verification process starts right away.

Collecting patient insurance information at intake means more than asking the patient which company insures them. It also means getting the patient’s insurance ID, policy number and, if applicable, group number. The patient’s insurance card should also have a phone number that providers can call, which you should record.

Additionally, you should check whether the patient or someone else is the policyholder. If applicable, record the policyholder’s full name and relationship to the patient. Group all the insurance information you’ve collected with the patient’s full name and date of birth, and you’ll have everything you need.

2. Reach out to the patient’s insurer.

Whether you have an excellent relationship with the patient’s insurer or have never worked with them before, contact them after collecting the patient’s information. You should reach out early because insurers cover so many people that they might need several days to acknowledge and act on your verification request.

Here’s what you should do when contacting a patient’s insurer:

1. Reach out by phone. Call the insurance provider’s number you collected from the patient and wait for a representative to answer. If you find yourself waiting for what feels like forever, call back later; insurance provider lines are often quite busy.
2. Speak with an authorized rep. Once you reach an insurance rep, verify that the person with whom you’re speaking is authorized to confirm a patient’s insurance details.
3. Confirm HIPAA compliance. Next, confirm with the rep that your current phone conversation is a HIPAA-compliant way to transmit patient information.
4. Share the insurance information. Then, share the insurance information you’ve collected from the patient. (More on this step below.)

Alternatively, many insurers have online portals where you can enter the patient’s data to verify their coverage and benefits. However, these portals have a reputation for being outdated, so your verification results could be inaccurate. Phone calls are generally best for insurance verification, but online portals can be a decent option in a pinch.

3. Ask the right questions when speaking with insurance reps.

With an insurance rep on the phone and your patient’s insurance information handy, you’re ready to learn the ins and outs of your patient’s coverage and benefits. Here’s what to ask:

• Ask the rep to confirm all the information you’ve gathered.
• Ask whether the policy is active and when it expires.
• Assuming the policy is active, ask the insurer what the patient’s copay will be.
• Collect information on the patient’s deductible, if applicable.

At this point, you’ll have confirmed all the basics of your patient’s insurance plan, but you shouldn’t stop there. Here’s what comes next:

• Determine whether any sort of insurance authorization is necessary before you see the patient.
• Ask about additional documentation or unusual coverage limits.
• Finally, ask any questions you know are pertinent to this specific payer from previous experience.

4. Start from the top before every patient encounter.

The three steps above comprise the entire insurance-verification process. However, patients can theoretically lose insurance or switch plans at any time. It’s best to collect the patient’s insurance information before each encounter or incentivize them to submit it through your practice’s patient portal. This notion holds whether you haven’t seen the patient in a year or a week.

Don’t just ask whether the patient’s insurance has changed, because the patient likely doesn’t know how recent your data is. Instead, show them all your information and ask whether it’s correct or needs updating. If the information you show the patient is correct, your insurance-verification process is complete. If not, start from the top.

The importance of verifying patient health insurance in medical billing

Insurance verification matters whether you’re newly opening a private medical practice or established your practice long ago. Verification is crucial for the following reasons:

• Insurance verification minimizes claim denials. Let’s say you have a patient’s insurance information from last year on file and assume it hasn’t changed. However, if it has changed, you could be sending claims to the wrong payer and receive an instant claim denial. You’ll need to contact the patient to determine their proper insurer and refile the claim with that payer. You’ve already lost time and money working on that initial claim.
• Insurance verification maximizes cash flow. Insurance verification reduces the likelihood of claim denials and improves your cash flow. Fewer denied claims mean more approved claims, so you get paid faster. With proper insurance information on all your patients, you’ll go to the right source for your reimbursements the first time.
• Insurance verification increases patient satisfaction. We’ve all been there: You went to the doctor for medical attention but walked away paying way more than you expected. Shouldn’t your insurance have covered the whole thing? As a practitioner yourself, you have the power to prevent these unhappy patient experiences. Verify the patient’s insurance before their appointment, then let them know what their plan does and doesn’t cover. This way, patients won’t face any costly surprises.

What is the difference between an insurance authorization and insurance verification?

Whereas insurance verification confirms a patient’s insurance information, insurance authorization obtains an insurer’s approval for specific services. This approval is separate from creating and filing medical claims. It’s a form of prior authorization for services instead of a retroactive motion for obtaining payment.

Insurance authorization may be necessary if specific treatments, prescriptions or tests become necessary for your patient’s care. Different payers have different rules about when authorization is required, but their goal is generally the same: to ensure that payer money goes toward fully necessary, high-quality services.

Some patients may also require insurance pre-authorization for any and all specialist visits. Often, a primary care physician referral entirely covers this need.

Best medical billing services for insurance verification

The front office staff often handles insurance verification, which can take up a staggering portion of their workday. If you prefer that your front office staff tend to your patients instead, consider outsourcing insurance verification to a third-party medical billing and collection service. Here are some of our picks for the best medical billing services to make the insurance verification process run smoothly.

• AdvancedMD: AdvancedMD will thoroughly review all claims and spot errors before you submit them. Our AdvancedMD review explains how this platform lets you perform instant insurance eligibility checks on one or all of your appointments.
• DrChrono: With DrChrono’s denied-claim management features, spending time resolving denied claims is a thing of the past. Read our DrChrono medical billing software review to learn how this platform scrubs claims for errors and monitors their progress.
• athenahealth: This software platform includes a user-friendly medical billing dashboard where you can review your practice’s financial performance in a central location. Our athenahealth medical billing software review shares how this service will follow up with payers on all unpaid claims.

Understand health insurance verification and keep patient care on track

Verifying health insurance coverage is necessary to avoid disruptions in patient medical services. Follow these steps when you begin patient care to avoid any hiccups down the road. If the verification process is too time-consuming, you can always enlist the help of a third-party medical billing service. Once verification is taken care of, you can focus on the most important thing – providing the top-quality care your patients have come to expect.

Natalie Hamingson contributed to this article.