Eligibility and Benefits Checks

Eligibility and benefits checks have become both easier for many practices to conduct, and are increasingly necessary with the expanding complexity of medical insurance.  Checking eligibility and benefits has likely become easier for most with a move from paper charts to EMRs that support this functionality within the system.  Many EMRs allow users to retrieve a feed electronically from the payor on demand that provides detailed benefits information for patients.  The growing complexity of medical insurance has also made these checks more imperative.  Not only have the product offerings grown more complex, with narrow network offerings, exchange plans, Medicaid expansion plans, etc., but the benefit offerings themselves have grown more complex.

When training front-end staff on handling benefit checks, it’s important for them to understand what their goals are in conducting these checks.  We have seen many who incorrectly believe that a return of available insurance benefits means the physician can see the patient and everything will be covered.  Train your staff in a way that provides them with the larger picture surrounding this functionality, and the effect it has on the overall revenue cycle.

• Staff should understand that the patient having available benefits does not mean that the physician is in network for the particular plan held by the patient

• Ensure that staff understand how to check eligibility manually when an electronic verification is not possible, or requires manual follow up

• Depending on your specialty, ensure that staff understand how to read the benefits return to assess what is and is not covered

 People generally respond better when they have the full picture rather than being mandated to complete a task that they don’t fully understand.  Your revenue cycle will benefit from your staff having a better understanding of how this important function fits into the revenue cycle as a whole.