The principal challenge that most medical care providers face while claiming reimbursements is the chance of claim rejection and denial by payers. This not only results in financial loss for the hospitals or medical facilities but has the potential to strain their relations with the patients. Repetition of all the work for re-submission of the claim can be expensive and tedious.
Medical practices and hospitals must undertake several precautionary steps to evade any risks of claim rejection, fraudulent claims, or reimbursement delays. Two of the most vital steps in this process are conducting a fundamental insurance verification and obtaining insurance authorizations in cases that need it as a preliminary requirement. Both these procedures have a common aim but are a lot different in their respective implication and application.
Insurance verification: This is a process of checking patient’s insurance coverage and benefits prior to date of service to ensure insurance payments for the services rendered. This includes a simple cross-checking of vital data related to the patient who has enrolled himself to receive the medical treatment. You must collate all the information on the demography, medical history, insurance plan details, and more that will be required to submit the insurance claim.
Set aside a team to verify all the crucial details with the patient records to identify missing data or gaps or to assess whether the claim is genuine or not. If need be your team can reach out directly to the patients or the insurance payers to collect relevant information like other coverage details, PCP referral etc. Sometimes negligible errors as minute as a wrongly mentioned date of birth or the insurance Id number or misspelled names of the patients when compared to insurance data base can cause a claim to be rejected straightaway. Therefore, a thorough investigation of data to eliminate inaccuracies must be undertaken by subject matter experts.
Insurance authorization, or prior authorization or pre-authorization: Here the medical care provider seeks advance approval from the insurance payer on specific medical treatments, use of drugs, or medical equipment to be used as part of the medical service provided to the patient. The process directly impacts the probabilities of claim acceptance or rejection. The Insurance payer uses this procedure as an effective way to ensure quality and cost control while paying the claim.
When you send the authorization request to the payer, they analyze it around specific parameters and provide an approval or a rejection. They scrutinize the request carefully to understand whether the prescribed treatment is in line with the medical issue that the patient has complained of. Other concerns include whether the prescribed drugs are safe to be taken by the patient in combination with the other medicines he might already be consuming, whether the drugs or medical equipment recommended by the doctor have another alternative available at a relatively lower price, and also to check if there is any duplication of the prescribed treatment in cases where the patient is referring to multiple practices.
Following these vital steps, you will improve your insurance reimbursement ratio while seizing revenue leakages and delighting your patients.