An insurance policy protects people from substantial unexpected expenses and financial issues. People may encounter unfortunate events such as medical emergencies, accidents, or disasters. However, an insurance policy that helps cover these costs gives people peace of mind. Unfortunately, many healthcare providers struggle to fully verify insurance benefits. An eligibility check alone isn’t enough. The good thing is that insurance benefits verification outsourcing is now available to help healthcare providers. Thus, healthcare providers should use benefits verification services to ensure accurate, complete benefits verification of insurance policies.
An Overview of Eligibility Check and Full Benefits Verification
An eligibility check confirms active status on the date of service and validates effective and termination dates, member ID and group number. An eligibility check can identify the primary and secondary insurance, but not the specific service exclusions.
*All infographics created by Nicole Baleros
A full benefits verification, by contrast, provides information about copays, coinsurance, and remaining deductibles. A full benefits verification determines service-specific limitations, visit caps and in-network vs. out-of-network status. For authorizations, a full benefits verification determines whether you need prior approval or a referral.
A Comparison of Eligibility Check and Full Benefits Verification
The decision to use an eligibility check or full benefits verification depends on the clinical context, financial risk, and administrative capacity. However, healthcare providers should use full benefits verification for specialized, expensive, or surgical care. On the other hand, an eligibility check is effective for high-volume, routine, low-cost visits.
Why “Active Coverage” Isn’t Enough
Active insurance coverage only confirms that the policy is open. An active plan may exclude expensive procedures or specialized therapies. An eligibility check does not indicate procedure-specific coverage, remaining deductibles, or accurate patient cost estimates. As a result, healthcare providers face unforeseen financial gaps, claim denials, and unsettled patient balances.
How Insurance Benefits Verification Outsourcing Can Help
Relying only on “active coverage” is risky for healthcare providers. A substantial percentage of claim denials come from unverified benefits or service exclusions that an active status indicator does not indicate. Thus, healthcare providers should rely on a proven insurance benefits verification outsourcing provider and follow an action plan to complete verification.
Key Takeaways
An eligibility check confirms active status on the date of service and validates effective and termination dates, member ID and group number. A full benefits verification, by contrast, provides information about copays, coinsurance, and remaining deductibles. Active insurance coverage only confirms that the policy is open. As a result, healthcare providers face unforeseen financial gaps, claim denials, and unsettled patient balances. The good thing is that insurance benefits verification outsourcing is now available to help healthcare providers with full benefits verification.
Interested in Insurance Benefits Verification Outsourcing Services?
Magellan Solutions provides inbound and outbound call center services and business process outsourcing in the Philippines. We have extensive experience providing best-in-class outsourced solutions to small and medium-sized enterprises (SMEs) and large global enterprises. We are a generalist BPO company that applies a process-improvement mindset to our clients’ outsourcing processes.
