Updated: Nov 25, 2020
Benefit Verification is a critical component of all healthcare related visits. This step ensures all providers and healthcare facilities receive payment/reimbursement for all services rendered. When conducted properly, the healthcare provider will be able to determine the patient’s out of pocket responsibility. Eligibility is conducted to ensure the patient has active coverage with the payer. Benefit Verification is to ensure the services rendered are a covered benefit under the payer for the member/patient.
Eligibility and Benefits should be verified before each visit transpires. Doing so will indicate a change in coverage to include but not limited to out of pocket cost and pre-authorizations.
Here are some of the items that are you able to obtain from the carrier when you are conducting benefit verification:
Plan & coverage details
Claims mailing address
Referrals & pre-authorizations
Lifetime maximum benefits
Patient policy status
Some patients will have more than 1 carrier. In cases such as these, you will verify if the coordination of benefits (COB) is on file with all payers. The benefit verification process will cover the coordination of benefits with secondary and tertiary payers.
Conducting proper eligibility and benefits before the visits ensures patients have an estimation of out of pocket cost for the services rendered and are willing and able to pay or make the proper payment arrangements.
Having proper policies in place is a key component of the financial success of a healthcare organization.
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