Benefit Verifications vs Eligibility Verifications

Hello and Happy Friday! Welcome to your Weekly R & R, where we give you the Rundown on important billing topics and all things Revenue to help your practice thrive!

Today we are talking about the difference between Benefits Verification and Eligibility Verification.

They sound very similar, but with a very important difference that can lead to claim denials and prolong or reduce your reimbursement… so let’s jump right in and run it all down for you!

 

What is a Verification of Benefits?

A verification of benefits is confirming the specifics of coverage of a patient’s medical policy. The benefits will detail the specific patient responsibility financially (Deductible, Coinsurance, Copay, Out of Pocket Information) as well as other important information. This information can include determining what code(s) require prior authorization, limitations, restrictions, or exclusions in a patient’s policy. When doing a Verification of Benefits, you can also confirm provider/facility participation in a specific plan, and other details that could impact a claims payment.

 

What is a Verification of Eligibility?

A verification of eligibility confirms that a patient’s medical policy is active and effective for a specific date of service.

 

The Rundown: 

• The eligibility and benefits of a patient can change at any time, making it difficult for the patient and medical staff to keep up with their current plan coverage and patient responsibilities. By having BPS as your partner and implementing a clear protocol to check confirm each patient’s benefits we can work together to make sure your office and your patients have all the information needed to best proceed with an appointment. When patients are notified of their approximate sum before appointments or procedures, they have time to prepare for any out-of-pocket expenses and are much more likely to come to the appointment prepared to pay or make payment plans.
• In situations where insurance has expired or plans do not cover the programs, checking eligibility and benefits in advance protects your offices cost of a procedure.

 

Why is this Important?

According to Change healthcare’s 2020 denial index report, front-end revenue cycle issues are responsible for half of all denials! Of that 50%, Eligibility is approaching 27% on its own with Authorization/pre-certification not far behind at 11.6%. (“2020 Revenue Cycle Denials Index”)

This means that majority of these denials are completely preventable yet responsible for major revenue loss in practices just like yours.

The eligibility and benefits of a patient can change at any time, and most insurance companies have very specific requirements for prior authorization depending on network status, place of service, etc.

I think they like to do this to keep us on our toes, right?

Regardless of the hoops we must jump through, the important thing to know is, lack of communication with insurance carriers prior to a patient visit may lead to rise in claim denials and a sizeable loss of a revenue.

By confirming the patient’s active coverage and benefit details, you are giving your patient the knowledge and understanding about their insurance improving your patients overall experience.

Furthermore, this information of how the plan will process a claim, if authorization is required, and how the patient’s benefits will apply to a procedure will aide in preventing claim denials and streamline your revenue cycle.

 

Prevention is key and knowledge is Power! 

Our team of experts at Billing Partner Solutions follow a process, customized to your office, for checking benefits, staying current on changes and trends in the industry, and educating our team, clients, and our client’s staff on the key things that will help your patients overall experience. This will help streamline your revenue cycle, reduce denials, and keep your practice thriving!

Thank you for taking your time today to spend with us. We hope this information was helpful!

Come back next week because we are pulling back even more layers about claim denials that you are not going to want to miss.

See you back for your Friday R & R with your favorite Billing Partners delivering Solutions.

 

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References:

2020 Revenue Cycle Denials Index.” Change Healthcare, Jan. 2021, https://newsroom.changehealthcare.com/in-the-news/revenue-cycle-denials-index.

https://newsroom.changehealthcare.com/in-the-news/revenue-cycle-denials-index