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Why Insurance Verification is Important

Why Insurance Verification is Important

As a medical biller, there are so many steps to take, that we often forget that if there are ways to be more efficient, maybe more things can be completed within our work days and week. There are a lot of steps to billing out claims and getting those claims reimbursed. One of the most important steps in the medical billing process is the insurance verification process. Before billing medical claims, make sure the claims are billed accurately and with the correct information. It would be inefficient to bill claims only to find out they were denied due to misinformation. So, here are five reasons why it is important to check a patient’s eligibility before billing and filing claims.

To Confirm Patients Policies are Active

When a patient comes into a physician’s office for medical services and provides their information and insurance card, the first step is to check the patient’s eligibility and benefits. This will allow you to confirm if the patient’s policy is active for the date they are receiving service. This ensures that you are able to bill the claim to the patient’s insurance. Also, it will allow you to confirm if there is any patient responsibility upfront (copays) so while the patient is in the office, you are able to collect the copay, or if they’ve met their deductible and out-of-pocket amounts that way once the claim is processed the remaining amounts may apply to their deductible or out of pocket if they have not met it. This step is important for all providers small or large. If the patient’s policy is inactive, then you will know that a claim should not be billed to an insurance payer where the patient has no coverage, so that the patient is fully responsible for paying for their service. If this step is missed, you could possibly bill a claim to the insurance company which the patient gave you, only to find out the claim was denied because the patient’s plan is inactive or they have another insurance provider, which leads to the next reason why checking eligibility is important.

To Confirm Claims are Filed to the Correct Insurance Carrier

Medical billers bill thousands of claims every day and because of this, it is important that eligibility is checked every day to ensure that claims are being filed to the correct insurance payer. Once it is confirmed that the patient has an active policy, make sure you are aware of where the claim should be sent. Insurance companies have many addresses for all of their departments all over the world. You can look on the front or back of the insurance card for the claims address, or if there is no card on file, but an insurance form while checking the patient’s eligibility, ask the insurance representative where you should file the claim and the claims address, so once you have billed the claim it can be sent to the correct insurance. Also, look for the insurance carrier's electronic data interchange number (EDI). That way if you are filing an electronic claim the insurance address as well as the EDI number match in your billing system and clearing house systems for the claims to be transported electronically to the correct insurance. This step also helps with patient’s who’s insurance may be through a large insurance company but whose policy may be managed by a third-party administrator (TPA). So you will need to figure out if the claim should be sent to the large insurance corporation claims department or the TPA. This could help decrease the rate of returned or denied claims that go to the wrong payer.

Physician Referrals & Prior Authorization for Services

Checking eligibility also informs you if a referral is needed from the patient’s primary physician. This may occur if you bill for a specialist office. if the patient’s policy covers the service that is being provided and if prior authorization is required, then you will have to submit additional paperwork or make a phone call to the patient’s insurance carrier. Or contact the patient’s primary physician and request authorization for the patient to see a specialist. Once authorization has been completed and the authorization number has been obtained, then the services authorized can be rendered. 

Determines Procedural Coverage for the Patient’s Insurance Plan

Checking a patient’s eligibility can also help you determine whether a procedure is covered under the patient’s plan or not. You want to make sure the procedure codes are valid and billable for the patient’s plan to determine if the service will be covered. It is important to find this out ahead of time, so you will know if it will be paid or not. That way you can prepare the patient that if their plan does not cover the procedure they (the patient) could potentially be responsible for the cost if they proceed with the service they are being provided. It would not be good to bill the patient’s insurance only to find out that the service is not covered under the patient’s plan and the insurance company applies it to the patient’s deductible. A patient would not be happy receiving a bill in the mail for something they had no idea was not covered under their insurance plan. This is why it is important to receive this information up front and to inform the patient of their responsibility if any. Also making sure that the patient has both in and out-of-network coverage is helpful just in case they are seeing an out-of-network provider, the patient knows what they are responsible for.

Helps Decrease Claim Denials

Let’s face it, as a medical billing specialist you will always have to deal with denials, but checking eligibility could help decrease the denials you encounter. Most denials are because eligibility was not completed. Denials such as inactive policies, and prior authorization can increase denials and workloads for specialists. Simply obtaining the eligibility information, can decrease these denials and allow the billing specialist to work on or appeal the more important denials.

A lot of information can be acquired about the outcome of the claim before it is even billed. There are many ways you can check patients’ eligibility information, whether you use online resources to provide you with the information, or if you contact the payers by phone. With the growing evolution of technology, acquiring eligibility information is easily obtainable. As long as you register with the insurance carrier web portals, you are able to get the information you need. If you do not see information relating to prior authorizations online, you can still utilize the provider phone numbers that most insurance carriers have for more specific questions. When obtaining the information via phone, be sure to get a call reference number from the insurance representative and notate the accounts with this, so that you can keep a record of any phone conversations about an insurance policy for your records. 


If you bill for a provider, you may want to try to implement some of these reasons in your workflow to help with any denials you may be dealing with and see how it could benefit you and the provider you bill for. If you can, put together an insurance verification or data entry team to obtain eligibility information so that when you bill the information has already been obtained and the claim can be submitted and processed correctly the first time. If not, then you could be dealing with a lot of denials and this could potentially interfere with re-filing the claim before timely filing occurs. The longer the claim takes to re-file, the less money you may get for that claim. So, how do you or your billing team handle insurance verification?