Objective :

To verify patient insurance coverage, eligibility, and specific benefits prior to service to ensure accurate billing, reduce claim rejections, and enhance patient communication regarding financial responsibility.

Coverage & Eligibility Verification :

Purpose :

Confirm that the patient has active insurance coverage and determine if the provider is in-network.

Key Steps:

  • Collect Patient Information
  • Full name, DOB, insurance ID
  • Policyholder name (if different)
  • Provider NPI/Tax ID for in-network validation

Verify Through:

  • Payer Web Portals
  • Clearinghouses (e.g., Availity, Change Healthcare)
  • Direct Payer Calls (for out-of-network or secondary coverage)

Information to Confirm:

  • Effective dates of coverage
  • Policy status (active/inactive)
  • Plan type (HMO, PPO, Medicaid, etc.)
  • In-network vs. out-of-network coverage

Benefit Detail Verification :

Purpose :

To determine what services are covered, at what rates, and what patient responsibilities apply.

Key Items to Verify:

  • Deductibles: Total, amount met to date
  • Co-pays: Based on visit type (e.g., specialist, primary, telehealth)
  • Co-insurance: % responsibility after deductible is met
  • Out-of-pocket max: Total and remaining balance
  • Procedure codes: (e.g., ABA, Mental Health, surgery, and what not)
  • Authorization requirements: Determine if prior auth or referral is needed
  • Limits/Exclusions: Number of visits allowed per year, diagnosis restrictions

Documentation & Communication :

Purpose :

To ensure that verified benefits are recorded and communicated clearly to billing staff and/or patients.

Our Best Practices:

  • Use standardized VOB forms/templates.
  • Include payer rep name and reference # if verified by phone.
  • Attach VOB to patient record in the EHR or practice management system.
  • Flag issues or required pre-approvals for the clinical or billing team.
  • Communicate expected out-of-pocket costs to patients upfront, if possible.

Benefit Re-verification Triggers:

  • At each new plan year or benefit reset
  • Before high-cost services.
  • For chronic care patients or those with frequent visits.
  • If a payer denial occurs due to eligibility or benefit issues.

Our Best Practices for Efficient VOB:

  • Use automated eligibility tools where available (e.g., integrated into PMS)
  • Maintain a payer contact directory for escalated benefit inquiries
  • Develop scripts for payer calls to ensure consistency
  • Keep a log or tracker of all verifications performed for auditing and reference
  • Train front desk or intake staff to perform real-time checks when scheduling

Why It’s Important:

  • Reduces claim denials due to eligibility issues or non-covered services
  • Increases patient transparency and satisfaction
  • Enhances cash flow by minimizing payment delays and rework.