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Best Practices for Verifying Patient Eligibility and Benefits

Patients are taking on more financial responsibility as consumerism rises. The increasing popularity of high-deductible health plans (HDHPs) is a clear indication of this trend. As a result, it is critical to clearly understand the patient’s responsibility for upfront payments and coverage.

This article emphasizes the significance of verifying patient eligibility and benefits.


What Is the Difference Between Patient Eligibility and Benefits Verification?

A medical billing services provider must confirm the patient’s coverage for medical services and determine their financial responsibility. Physician practices can confirm the coverage offered by the health plan as well as copayments, deductibles, and co-insurance with the health plan through the patient eligibility and benefits verification process.

Eligibility verification encourages the collection of coverage status and reduces the likelihood of claims being denied. It enables healthcare providers to collect payments from patients in advance, avoiding cash realization delays.


Information Required to Check Patient Eligibility and Benefits

One of the most important aspects of front office service is gathering patient information and allowing insurance verifiers to verify benefits.


Information Required by Insurance Companies

1) The name of the subscriber

2) The patient’s name

3) Relationship between the patient and the subscriber

4) Date of birth of the patient

5) Gender of the patient

6) Patient identification number

7) Name and number of the group

8) Plan design

9) Date of coverage (policy effective date)

Elements of Insurance Verification

1) Tax Deductibles

2) Co-payments

3) Co-insurers

4) Reimbursable benefits

5) The status of the patient policy

6) Date of application

7) Plan type and coverage information

8) Exclusions from the plan

9.) Make a mailing address claim


Healthcare providers must educate their employees about the practice audit and reporting services. Processing efficiently reduces the likelihood of denials and speeds up the cash flow cycle.


Processes for Electronic and Manual Eligibility Verification


  • Most payers have made online eligibility checkers available. You will be able to save time by electronically verifying eligibility prior to the scheduled patient appointment. 
  • Obtain accurate information about the patient’s insurance status and comprehend the health plan’s benefits. 
  • Determine whether or not you must collect a co-pay at the time of service. 
  • Update insurance information 
  • Request that patients update their primary care physician information. 
  • It is sometimes necessary to contact the payer with questions about prior authorization requirements or to clarify some eligibility and benefits elements.


The Significance of Process Documentation

Your practice’s requirements are distinct. A substance abuse treatment center’s eligibility verification requirements are very different from those of a hospital or radiology clinic. As a result, each institution must develop its own eligibility and benefits verification workflows. All members of your team must work together effectively to ensure that all steps are completed efficiently.


Competencies in Eligibility and Benefits Verification for Medical Billing Wholesalers

Efficient eligibility and benefits verification processes are critical to the financial health of your organization. The process is also responsible for the majority of claim denials. You must constantly improve and learn from each denial. Medical Billing Wholesalers provides experienced revenue cycle workers to assist your front-office staff with eligibility and benefits verification. Our comprehensive revenue cycle solutions can assist you in lowering costs and increasing efficiency.


Iqra Haseeb


Organised and efficient Team leading Manager, supporting corporate level officers and senior management personnel with demonstrated expertise in financial and operational leadership. Adroit professional exemplifies multi-disciplinary managerial skills in process procedure and policy improvement initiatives. Accomplished in workflow optimization techniques implementation which increases productivity, reduces labour, and maintains business integrity and quality of service.


Extensive Client Coordination., Conducts business analysis to create value, Provide Support in creating or enhancing the business, Develop and manage strategic partnerships to grow business, Provide Insights or Conduct Studies related to Market or Business Operation related problems, Provide assistance in operating and handling the business, Develop and structure concepts, strategies, automating and scaling the business


Developed and implemented favourable pricing structures balancing firm objectives against customer targets., Education Coordinated innovative strategies to accomplish marketing objectives and boost long-term profitability., Reached out to potential customers via telephone, email and in-person inquiries., Worked with existing customers to increase productivity of  services.

Sharjeel Khan


Having 10 years of experience in the Medical Billing Industry & up to date with Government, Commercial, Automobile & Workers Compensation Payer guidelines throughout the U.S.
Strong knowledge of claims procedures and coding, account receivable/collection, Denial Management, Credentialing/EDI Enrollments and Revenue Cycle Management. Experienced in Electronic Claim (5010) Loop and Segment Editing, Creating Paper to Electronic Claims (EDI 837), Resolving EDI Rejections through Practice Management & Clearing house, creating invoices, customized provider reports, Auditing, processing insurance & patient payments, and pursuing past-due balances through unique & proven RCM process and Data Management.


ICD-10-CM, CPT, Coding Guidelines, Diagnosis Coding, Compliance, Facility/Professional Coding, Complete Revenue Cycle Management, Telehealth or Virtual Visits, Provider Education, CMS-1500, Upper hand in almost every top PM/EMR/EHR Software used, and many more...


Behavioral/Mental Health, Neurology, Family/Internal Medicine, Infectious Diseases, Pulmonary & Sleep Medicine, Pain Management, Physical/Sports Medicine and Rehabilitation (Physiatrist), Chiropractic, Podiatry, Radiology, and much more.

The Full-Service Bundle includes;
  1. Medicare for both one practice county and one provider
  2. Medicaid for both one practice location and one provider
  3. BCBS PID for both the practice and one provider
  4. RailRoad Medicare for both one practice county and one provider