Process of Verifying Patient Health Insurance

According to the latest data from the 2024 CPS ASEC (Current Population Survey Annual Social and Economic Supplement), 92% of the U.S. population, or approximately 305.2 million people, had health insurance for all or part of 2023. This highlights the widespread Insurance coverage achieved during the year. 

Health insurance is essential in the U.S. due to its privatized healthcare system, where high medical costs make coverage necessary to avoid financial strain. You may benefit from employer-sponsored health insurance, while government programs like Medicare and Medicaid provide coverage for seniors, low-income individuals, and those with specific healthcare needs.

PT clinics and healthcare providers must prioritize thorough insurance verification to reduce financial risks from uninsured patients. This ensures timely reimbursements, prevents claim denials, and clarifies patients’ financial responsibilities. Efficient verification streamlines billing processes, minimizes administrative burdens, and enhances overall financial performance for practices.

In this article, you'll explore the detailed process of verifying health insurance and learn how platforms like SPRY PT simplify insurance verification, ensuring smooth access to coverage.

The Process of Verifying Patient Health Insurance

Step 1: Collect Patient Information

The first basic step in the health insurance verification process is gathering key patient details. Here’s a complete breakdown of this process:

1. Gather Essential Patient Demographics:

• Start by collecting the patient’s personal information, which includes their full name, date of birth, and current address.
• Ensure that this information matches exactly with what the insurance company has on file to avoid issues during verification.

These details are important for accurately identifying the patient in your system and the insurance company’s records.

2. Collect Insurance Details:

• Obtain the insurance policyholder’s details. The policyholder may or may not be the patient, as the policyholder could be a spouse, parent, or other family member.
• Record the policyholder’s name and their relationship to the patient, as well as the policy number and group number, if applicable. 

These details are essential for verifying coverage and billing correctly.

3. Acquire Insurance Company Contact Information:

• Collect customer service phone number, claims department contact, and mailing address.
• In addition to the policy details, it’s important to gather the contact information for the insurance company. 

Having this information on hand will make it easier to contact the insurance company for verification, pre-authorization, or claims inquiries.

4. Inquire About Secondary Insurance:

• This is particularly important for patients covered under multiple plans, as it can help maximize coverage and reduce out-of-pocket expenses. 
• If the patient has multiple insurance plans, you should inquire about secondary insurance. 
• Collect the same detailed information for the secondary insurance policy to ensure all parties are correctly billed.

By thoroughly collecting and recording this information, you set the foundation for a smooth verification process, minimizing the risk of errors, claim denials, or payment delays. 

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Step 2: Obtain an Insurance Card and Photo ID

Once the patient information is collected, the next step is to gather and document their insurance card and a valid photo ID. This ensures the accuracy of the insurance details and verifies the patient’s identity. Here’s a precise explanation of the process: 

1. Make Copies of the Front and Back of the Insurance Card:

• Start by obtaining a copy of both the front and back of the patient’s insurance card.
• The front typically includes essential information such as the insurance company name, policy number, and member details, while the back provides contact numbers for claims, authorizations, and verification services. 

Both sides are critical for processing claims and verifying coverage, so having clear copies ensures all necessary details are easily accessible.

2. Scan the Patient’s Insurance Card and Photo ID for Records:

• After making copies, scan both the insurance card and a government-issued photo ID, such as a driver’s license or passport.
• The photo ID is essential for confirming the patient’s identity and ensuring that the insurance information matches the correct individual.

This scan serves as a secure digital record, allowing for quick and accurate reference whenever needed. 

3. Keep Scans for Easy Future Reference to Verify Details:

• Store these scans in the patient’s electronic medical records (EMR) or practice management system. Platforms like SPRY PT streamline this process with automated eligibility verification and integrated billing. 
• These scans also help avoid confusion or delays when dealing with insurance companies, particularly when re-verifying coverage or handling claims.

Having these records readily available allows staff to quickly retrieve and review the information during future visits, or when re-verifying insurance coverage. 

Suggested Read: Insurance Made Easy: Navigating In-Network and Out-of-Network Benefits with SPRY

Step 3: Input Information into the EMR

Once the patient’s demographic and insurance information is collected, it’s important to accurately enter this data into your system for future use. This step is essential for streamlining administrative processes and ensuring smooth verification and billing. Here’s a brief look at how to perform this step: 

1. Add Patient’s Demographics and Insurance Details into the EHR, PM, or RTE Tool:

• Enter all the patient details, including their name, date of birth, address, and contact information, into your Electronic Health Record (EHR), Practice Management (PM), or Real-Time Eligibility (RTE) tool. 
• Input the insurance information such as policy number, group number, and insurance company contact details.

SPRY PT is a physical therapy management software that provides an all-in-one solution for clinics, focusing on features such as EMR( Electronic Medical Record), insurance eligibility, billing, and patient management. Start a Free Trial here! 

These platforms help organize and store patient data, making it accessible for future billing and health insurance verification purposes. 

2. Prepare and Use a Verification Checklist:

Create and follow a verification checklist to ensure no critical information is missed. 

• Cover all necessary details, such as the patient’s demographic information, policyholder details, insurance plan specifics, and secondary insurance (if applicable). 
• Using this checklist, ensure that all required fields are completed and prevent potential errors or omissions during the verification process.

By meticulously entering patient and insurance details into the system and verifying with a checklist, you set a strong foundation for effective health insurance verification and future billing.

Step 4: Verify Insurance Eligibility

Once the patient's information is entered into the system, the next critical step is to verify their insurance eligibility. This ensures the patient's coverage is active and appropriate for the services being provided. Here's a breakdown of how to verify eligibility effectively:

1. Check the Patient’s Eligibility Electronically by Selecting the Appropriate Benefit and Service Type:

• Use your Electronic Health Record (EHR) or Real-Time Eligibility (RTE) system to electronically check the patient's insurance eligibility. You can consider platforms like SPRY PT for Insurance Verification, integrated billing, digital intake, appointment scheduling, and analytics. Try SPRY PT here!  

• Select the specific benefit and service type for the upcoming treatment or procedure.
• These electronic checks will confirm whether the patient is covered for the planned services.
  

2. Confirm the Validity of the Policy, the Policyholder, and the Relationship to the Patient:

• Ensure the insurance policy is active, and confirm the policyholder’s information is accurate.
• Verify the relationship between the policyholder and the patient, as any discrepancies could result in denied claims.

3. Identify Policy Details:

• Review the essential policy details, such as the policy’s effective date, term date, co-pay amounts, coinsurance percentage, deductible, and out-of-pocket maximum. 
• These factors will determine how much of the cost is covered by insurance and what financial responsibilities fall on the patient.
  

4. Determine if the Service Requires Pre-Authorization and Contact the Payer if Necessary:

• Some services, treatments, or procedures may require pre-authorization from the insurance provider to be covered.
• Check whether the planned service needs prior authorization and, if necessary, contact the insurance payer to obtain approval before proceeding.
  

By verifying insurance eligibility and policy details, you can confirm the patient’s coverage and avoid issues with claim denials or payment delays, ensuring a smooth and efficient billing process. 

Suggested Read: The Hidden Struggles of Insurance Verification in the PT Industry - The SPRY Solution

Step 5: Inform the Patient of Financial Responsibility

Once insurance eligibility is verified, it’s essential to communicate the patient’s financial obligations before proceeding with care. This step helps avoid confusion or unexpected expenses for the patient. Here’s how to handle this process:

1. Explain Patient Financial Responsibilities, Including Co-Pays and Coinsurance:

• Review the patient’s insurance policy details and explain their financial responsibilities, such as co-pays, coinsurance, and applicable deductibles.
• Ensure the patient understands how much they must pay out-of-pocket based on their coverage. Medicare reduces out-of-pocket costs but doesn't cover everything.
  

2. Provide the Patient with an Estimate of Visit Costs:

• Offer the patient a detailed estimate of the total cost of the visit or treatment, including any amounts not covered by insurance. 
• This estimate should include the expected co-pay, coinsurance, and any other fees, giving the patient a clear understanding of their financial obligation.
  

3. Gather Any Necessary Authorizations Before Providing Care:

• If the patient’s insurance plan requires pre-authorization for specific treatments or procedures, ensure all required authorizations are obtained before care is provided.
• This step avoids potential claim denials and ensures that the patient’s insurance will cover the necessary services.
  

4. Provide Details about In-Network and Out-of-Network Coverage: 

In-Network Coverage: When your patients use in-network services, their insurance has pre-negotiated rates with your practice or facility. 

This results in lower out-of-pocket costs for them, including reduced copays, deductibles, and coinsurance. Insurance companies typically cover a larger portion of the charges, making it easier for patients to manage costs.

• In-Network Benefits:some text
  • Lower Costs: Highlight the advantages and reduced expenses associated with in-network providers.
  • Higher Coverage Rates: Explain that services from in-network providers are typically covered at higher rates, resulting in lower out-of-pocket costs for the patient.

Out-of-Network Coverage: For patients seeing out-of-network providers, the lack of a contract with their insurance means higher costs. Patients will likely face increased copays, deductibles, or even full responsibility for the bill. 

Insurance may offer minimal coverage, and you might need to balance bill the patient for the difference between your charges and what their insurance reimburses.

• Out-of-Network Implications:some text
  • Increased Expenses: Inform the patient about the higher costs and limited coverage when using out-of-network providers.
  • Additional Fees: Clarify any extra charges they may incur and how these affect their overall financial responsibility.

• Alternative Options:some text
  • Support Programs: If out-of-network services are necessary, discuss alternative options or potential financial assistance programs to help the patient manage costs.
  • Choosing In-Network Providers: Encourage selecting in-network providers when possible to maximize coverage benefits and minimize expenses.
    

By informing the patient of their financial responsibilities upfront and gathering necessary authorizations, you help them make informed decisions about their care while reducing the risk of billing issues later. 

Step 6: Collect Payment Before Service

To ensure smooth financial operations and avoid payment issues, collecting the patient’s financial responsibility before providing services is important. Here's how to manage this process:

1. Ensure Collection of the Patient’s Responsibility Before Their Appointment or Treatment:

• Collect any out-of-pocket costs, such as co-pays, coinsurance, or deductibles, before the patient's appointment or treatment. 
• This step helps avoid complications after services are rendered and ensures that the patient and the provider are clear on the financial arrangement.
  

2. Enhance the Patient Experience by Minimizing the Risk of Surprise Billing:

• Discussing and collecting payments upfront reduces the risk of surprise billing after the treatment.
• This transparency helps foster trust and improves the overall patient experience, as they are fully aware of their financial obligations ahead of time.
  

3. Collect Co-Pays or Coinsurances Upfront to Improve Cash Flow:

• Collecting co-pays or coinsurances before the service improves the provider’s cash flow and reduces the likelihood of unpaid balances. 
• It also simplifies the administrative process by reducing the need for follow-up billing.
  

Collecting payments in advance ensures that the financial aspect of care is handled smoothly, contributing to a better experience for both the patient and the healthcare provider.

SPRY PT is a Medical Insurance verifier that provides integrated billing, digital intake, appointment scheduling, and analytics services. Subscribe here! 

Step 7: Regularly Reverify Insurance

Insurance coverage can change over time, so it’s essential to regularly verify a patient’s insurance to ensure ongoing eligibility. Here's how to approach this step:

1. Frequently Verify Insurance Eligibility Before Every Therapy Visit:

• For recurring treatments or multiple visits, such as therapy sessions, verify the patient’s insurance eligibility before each appointment.
• This ensures that their coverage remains active and avoids surprises regarding ineligibility or lapsed policies.
  

2. Update Records Monthly to Account for Any Changes in the Patient's Insurance:

• Conduct monthly checks to update patient records and confirm any changes in their insurance plan, such as new policy numbers, coverage limits, or plan type. 
• This proactive approach helps prevent issues with claims submission and ensures up-to-date information is available for future visits.
  

Regularly re-verifying insurance minimizes the risk of coverage issues and keeps patient records accurate, ensuring uninterrupted care and smooth billing processes.

Watch this video on YouTube to understand the process in simple steps explained by Inlera University on their channel - 5 Ways to Verify Patient Insurance

Streamlining Insurance Verification with SPRY PT: How SPRY PT Enhances Eligibility Checks for Seamless Coverage?

SPRY PT offers you helpful tools to streamline your clinic’s operations, especially regarding health insurance verification. Here’s how SPRY’s features and services make your job easier: 

Some of the Best Features: 

1. Real-Time Insurance Eligibility Checks: With SPRY, you can verify patient insurance instantly. This eliminates claim rejections and integrates seamlessly with your billing system, ensuring you never deal with manual data entry again.
2. Clearing House Integration: SPRY connects with multiple clearing houses, giving you immediate access to essential insurance details like copays, deductibles, and coverage limits. This makes navigating complex policies effortless.
3. Digital Intake Forms: SPRY also enables patients to submit their intake forms online before appointments. This saves you and your patients time, as the forms automatically sync with the EMR system, improving accuracy and workflow.
4. Automated Reminders and Appointment Scheduling: You can rely on SPRY to automate reminders for incomplete forms and handle appointment scheduling, allowing you to focus on patient care rather than administrative tasks.

Some of SPRY PT’s Services Include: 

1. Integrated Billing: SPRY’s billing system is fully integrated, reducing errors and simplifying payment, from eligibility verification to reimbursement.
2. EMR & Smart Charting: SPRY’s customisable EMR templates let you quickly document patient care, ensuring your notes are accurate and thorough.
3. Remote Therapy Monitoring (RTM): SPRY tracks patient progress remotely, allowing you to maintain high levels of care while reducing in-person visits.
4. Analytics Dashboard: SPRY provides detailed insights into your clinic’s performance, helping you identify areas for improvement and make data-driven decisions.

Conclusion

In conclusion, thorough and efficient health insurance verification is essential for ensuring smooth healthcare operations. It benefits both providers and patients by preventing claim denials and unexpected costs. Implementing automated verification software can significantly enhance your clinic’s efficiency by simplifying eligibility checks and minimizing errors. 

Platforms like SPRY PT offer software that provides real-time eligibility checks where you can remain on top of insurance payments, eliminate extra expenses for patients due to needless rejections, and save hours of front desk staff work. SPRY PT also works with both on- and off-exchange insurance providers, Medicare, and worker compensation to confirm insurance eligibility beforehand. Book a Free Demo here!