How to Verify Patient Healthcare Insurance

What is insurance verification?

Insurance verification is the process of confirming a patient’s insurance coverage and benefits prior to an encounter. More importantly, it’s the process of confirming that a patient’s insurance plan covers the services you provide and is in your network. If not, you can either block the patient from seeing you or inform them that they’ll have to pay entirely out of pocket for your services.

At some medical practices, the front-office staff handles insurance verification. In this case, insurance verification can comprise a staggering portion of a staff member’s workday. If you’d rather ensure that your front-office staff has ample time to interact with patients, you can outsource insurance verification to third-party medical billing companies. Our reviews of the best medical billing and coding services can help you decide which company, whether it’s the user-friendly Kareo or the highly customizable AdvancedMD, might be best for you.

The importance of verifying patient health insurance in medical billing

Insurance verification matters equally whether you have long been in practice or are just now opening a medical practice. 

• It minimizes claim denials. Let’s say you have a patient’s insurance information from last year on file and assume their insurance hasn’t changed. If their insurance has changed, then you could be sending claims to the wrong payer. The result is, of course, an instant claim denial. You’ll need to contact the patient to determine their proper insurer and refile the claim with that payer. Even so, you’ve already lost time and money working on that initial claim.
• It maximizes cash flow. The reduction in claim denials that results from insurance verification also improves your cash flow. Think about it: Fewer denied claims mean more approved claims, which means more money more quickly. With proper insurance information on all your patients, you’ll go to the right source for your reimbursements the first time.
• It increases patient satisfaction. We’ve all been there: You went to the doctor for medical attention, but you walked away paying way more than you expected. Shouldn’t your insurance have covered the whole thing? As a practitioner yourself, you have the power to prevent dissatisfactory patient experiences like this from happening. Just verify the patient’s insurance before their appointment with you, then let them know what their plan does and doesn’t cover. This way, patients don’t face any costly surprises.

What is the difference between an insurance authorization and insurance verification?

Whereas insurance verification is the process of confirming a patient’s insurance information, insurance authorization is the act of obtaining an insurer’s approval for certain services. This approval is separate from the process of creating and filing medical claims. It’s a form of prior authorization for services rather than a retrospective motion for obtaining payment.

Insurance authorization may be necessary if certain treatments, prescriptions or tests become necessary for your patient’s care. Different payers have different rules about when authorization is required, but their goal is generally the same: to ensure that payer money goes toward fully necessary, high-quality services. 

Some patients may also require insurance pre-authorization for any and all specialist visits. Often, a primary care physician referral entirely covers this need.

The health insurance verification process

To verify a patient’s health insurance, take the following steps:

1. Collect patient insurance information during intake and registration.

When was the last time you saw a patient intake or registration form without an area for the patient’s insurance information? When was the last time you heard an appointment scheduling call during which the patient wasn’t asked for their insurance info? You probably can’t think of the answer to either question, or maybe it’s simply never. There’s a reason for that. With a patient’s insurance information immediately available, your verification process starts right away.

Collecting patient insurance information at intake means more than asking the patient which company insures them. It also means getting the patient’s insurance ID, policy number and, if applicable, group number. The patient’s insurance card should also have a phone number that providers can call. You should record this number too.

Additionally, you should check whether the patient or someone else is the policyholder. Make sure to record the policyholder’s full name and relationship to the patient. Group all the insurance information you’ve collected with the patient’s full name and date of birth, and you’ll have everything you need.

2. Reach out to the patient’s insurer.

Whether you have an excellent relationship with the patient’s insurer or have literally never worked with them before, contact them once you have the patient’s information. You should reach out early on, as insurers cover so many people that they might need several days to acknowledge and act on your verification request. 

To start, try reaching out by phone. Call the insurance provider number you collected from the patient and wait for a representative to answer. If you find yourself waiting for what feels like forever, call back later, as insurance provider lines are often quite busy.

Once you reach an insurance rep, verify that the person with whom you’re speaking is authorized to confirm a patient’s insurance details. Next, confirm with the rep that your current phone conversation is a HIPAA-compliant way to transmit patient information. Then, share the insurance information you’ve collected from the patient. See the next step for tips on doing so effectively.

Alternatively, many insurers have online portals in which you can enter the patient’s data to verify their coverage and benefits. However, these portals have a reputation for being outdated, so the results of your verification could be inaccurate. Phone calls are thus generally best for insurance verification, but online portals can be a decent option in a pinch.

3. Ask the right questions.

With an insurance rep on the phone and your patient’s insurance information handy, you’re ready to learn the ins and outs of your patient’s coverage and benefits. To start, ask the rep to confirm all the information you’ve gathered. Then, ask whether the policy is active and when it expires. Assuming the policy is indeed active, you should ask the insurer what the patient’s copay will be. You should also collect information on the patient’s deductible.

At this point, you’ll have confirmed all the basics of your patient’s insurance plan, but you shouldn’t stop there. You’ll now need to find out whether any sort of insurance authorizations are necessary before you see the patient. As you inquire about these needs, ask about additional documentation or unusual coverage limits as well. Finally, ask any questions that you know are pertinent to this specific payer from previous experience.

4. Start from the top before every patient encounter.

The three steps above comprise the entirety of the insurance verification process. However, patients can theoretically lose insurance or switch plans at any time. It’s best to collect the patient’s insurance information before each and every encounter, or to incentivize them to do so through your practice’s patient portal. This notion holds true whether you haven’t seen the patient in a year or a week.

Don’t just ask whether the patient’s insurance has changed, as this question doesn’t tell the patient the date of your most recent data on them. Instead, show them all the information you have and ask whether it’s correct or needs updating. If the information you show the patient is correct, then your insurance verification process is complete. If not, start from the top and don’t cut corners. Your cash flow, claims denial rates and patient satisfaction are on the line.