Revenue Cycle Time Line: Insurance Verification

This article has links to allow easy access time line content from Scheduling to Bad Debt Recovery. Use this information as a starting point for planning, SWAT Analysis, or to review policies and procedures for gaps. Create a time line for your facility to assure all participants share the same expectations.

Goals:

· Minimize losses and delays associated with billing plans inaccurate or expired insurance benefits

o Documented contact with ins companies or benefit verification databases to confirm current eligibility and benefits.

o Assure documentation is available for appeal if needed

o Assure accurate data entry into HIS

Activities and Considerations:

HIPAA and technology have combined to provide several options for automating the verification of insurance benefits. With the rapid growth of self pay portions, the urgency of early verification grows.

Upon confirmation of insurance coverage, several data elements must be entered. When possible, these should be uploaded from the external data source to reduce keying errors. Because some benefits must be entered manually, edit masks should be used where insurance plans have consistent policy number lengths and alpha-numeric rules.

Verification data input in the HIS should include:

· Patient Name

· Patient Date Of Birth

· Subscriber Name

· Patient Relationship to Subscriber

· Policy Number (and Group Number if applicable)

· Policy start and end dates

· Pre-existing Condition indicators

· Deductible, coinsurance and copayment information

· Maximum Out Of Pocket (annual)

· Maximum benefits (month/year/service specific)

Verification source should be a part of data captured. Sources should include:

· EDI/Direct payer inquiry

· EDI/third party clearing house inquiry

· Web/payer site inquiry

· Web/third party clearing house inquiry

· Web/patient data entry

· Phone/Call to third party payer

· Phone/Call with patient

· Phone/Call with physician

· Phone/Call with employer

All contact should be recorded and stored as part of patient records for both QA sampling and recovery of un(der) paid insurance benefits. Recording should include the ability to capture phone call, web data, email and fax