Verifying patient insurance: A checklist of questions and steps
Practices and billing companies can both benefit from this checklist on how to master insurance verification and prevent claim denials.
At a Glance
- Thorough insurance verification starts with confirming network status and plan type (HMO, PPO, EPO, etc.), which determines critical requirements like referrals and provider participation rules.
- Different insurance types (Medicare, Medicaid, commercial) have unique verification requirements and coordination of benefits rules that must be understood to ensure proper claim submission and payment.
- Successful verification requires checking specific details like pre-authorizations, benefit coverage, patient responsibility amounts, and coordination of benefits to prevent claim denials and billing surprises.
Clarifying insurance coverage and patient responsibility helps avoid billing surprises and claim delays. When healthcare practices — and the billing companies supporting them — verify the correct details early on, it ensures that coverage is applied properly and claims move through the system without issues. An efficient verification process benefits everyone involved, and taking the time to do a complete insurance check is key.
We’ve put together a list of essential questions and steps to help you gather all the necessary information.
Verification step 1: Is the patient’s provider in-network?
The first verification step is determining whether the provider is enrolled in the patient’s insurance network.
Questions for in-network insurance
These questions can help you confirm the necessary details for in-network coverage.
What type of plan is it?
Plans include HMO, PPO, EPO, POS, Medicaid, and Medicare. Each type has its own rules, provider networks, and referral requirements.
Is the patient eligible for the visit date?
Lapsed policies or plan changes can affect coverage dates, so confirm the coverage is active for the service date.
Does the patient have any other insurance?
If the patient has additional insurance, you’ll need to coordinate benefits and ensure claims are submitted in the correct order.
Does their plan cover the type of visit?
Some plans may only cover emergency visits or preventative visits. Certain types of care, such as specialist or mental health services, are excluded from some plans or may require pre-approval to receive coverage.
“Some plans may only cover emergency visits or preventative visits.”
Does their plan cover specific benefits?
Confirm whether the patient is responsible for copays, coinsurance, a deductible, or an out-of-pocket maximum.
Questions for out-of-network insurance
Refer to these questions when a patient wants to use out-of-network coverage.
Does the patient’s plan have out-of-network benefits?
The level of out-of-network coverage can vary significantly between plans. It’s essential to verify and inform the patient of their responsibility upfront.
Is the provider covered in the network used for out-of-network claims?
Some payers contract with an additional network for out-of-network claims, helping reduce patient costs.
Does their plan cover specific benefits?
Confirm whether the patient is responsible for copays, coinsurance, a deductible, or an out-of-pocket maximum.
Verification step 2: What type of plan is it?
The type of plan determines how the payer network functions. Confirming this ensures you understand the plan’s critical rules and requirements.
Health Maintenance Organization (HMO)
For primary care practices, start by confirming if the provider is listed as the PCP. If not, the patient must update that. For specialties, determine if their insurance requires a referral. Many HMOs require a referral from the PCP for specialist visits.
Exclusive Provider Organization (EPO)
Always double-check your participation in these plans. These are limited networks and are not automatically included in your contract. They are usually by invitation only and don’t have out-of-network benefits.
Medicaid
Make sure to verify if they opted for an HMO or MCO plan. These replace straight Medicaid and offer more flexible enrollment. A patient’s plan could change as frequently as once a month, and unlike traditional Medicaid, may require a PCP change, referral, or authorization.
“Make sure to verify if the patient opted for an HMO or MCO plan.”
Do they have other primary insurance?
The Medicaid eligibility response will always tell you if Medicaid believes they should be the secondary payer and who the primary payer should be.
Medicare
For professional billing, do they have Medicare Part B?
Some patients will only have Medicare Part A, which is only for institutional claims.
In addition, make sure to verify if they opted for Medicare Part C, commonly referred to as a Medicare Advantage plan, HMO, or MCO, which replaces Medicare Part B. These plans can be updated monthly, which might mean new requirements, like a PCP change, referral, or authorization, unlike traditional Medicare.
Are they a qualified beneficiary?
This means they have Medicaid as secondary coverage. In this case, Medicare will cross over to Medicaid, and you cannot collect the coinsurance from the patient.
Do they have other primary insurance?
The Medicare eligibility response will always tell you if Medicare believes they should be the secondary payer and who the primary payer should be.
- For the secondary payer, verify the MSP type. This will also be included in the eligibility response.
- Medicare Secondary Payer type-examples:
- A. 12 Medicare Secondary Working Aged Beneficiary
- B. 43 Medicare Secondary Disabled Beneficiary
Verification step 3: What to know about coordination of benefits (COB)
Knowing the following can help make COB a little easier:
- Medicaid will never be primary to any other type of insurance.
- Medicare will not be primary to commercial insurance except in very few scenarios.
- The Veterans Administration or TRICARE Prime will never pay secondary. You bill them as primary, or you don’t bill them at all.
- When there are 2 commercial payers:
- For a child covered by both parents, usually, you should use the birthday rule — the month that comes first would be primary.
- For spouses who both have coverage, each spouse would have their own policy as primary, and the other spouse’s policy would be secondary.
Extra tips for insurance verification
A knowledgeable approach to verification can reduce the workload involved in determining eligibility.
Here are a few more pro tips:
- Always check to see if you need to get pre-authorization.
- For copays, coinsurance, and deductibles, verify the amount and exactly what it applies to. For out-of-pocket maximums, confirm what can be applied to the allowed amount.
- Medicare and Medicaid coordination of benefits (COB) are easy to access through online tools, portals, or databases. Many commercial payers require a phone call to verify COB.
Minimize billing surprises
By following this comprehensive checklist for verifying patient insurance, practices and billing companies can reduce claim denials, streamline reimbursement, and enhance the patient experience. A well-structured insurance verification process not only prevents costly billing errors but also builds trust by providing patients with clear expectations of their financial responsibility.
Tebra’s comprehensive solution for medical billing companies helps you efficiently manage insurance eligibility and claims, eliminating issues that interfere with revenue collection. Take a product tour or schedule a demo to learn more.
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