RCM - Healthcare Eligibility Explained: A Quick Look

Healthcare eligibility checks are one of the fundamental steps of an RCM process. It is like checking your boarding pass before a flight - it confirms you have the right insurance "ticket" for the medical service you need. Here's a breakdown:

What it is: It's verifying a patient's health insurance coverage, benefits, and eligibility to receive specific services.

Why it's important: This ensures the healthcare provider gets paid and the patient avoids surprise bills. Imagine you show up for surgery expecting coverage, only to find out it's not included in your plan! Verification avoids this.

The Process:

There are two main ways to verify eligibility:

Electronic Check: This is faster and more common. The provider uses a secure system to contact the insurance company electronically and gets real-time confirmation of coverage details.

1. Check via Online Insurance Portals (Direct to Payer & Availity
2. Check via the EDI

Manual Check: This involves calling the insurance company directly on the Phone or having the patient contact them. It's slower and can be prone to errors.

Others are;

• Through Clearinghouses (a middleman(institution) between a healthcare provider(s) & insurance carriers)
• Real Time Eligibility Checks (EHR (Electronic Health Records) & other Management software programs

What's Checked?

Coverage Status: Is the insurance plan active?

Benefits: What services are covered by the plan (office visit, X-rays, etc.)?

Specifics: Deductible (amount you pay before insurance kicks in), copay (fixed amount for a visit), and coinsurance (percentage you share after deductible).

Example:

John needs an appointment for a sprained ankle. His doctor's office electronically verifies his insurance. The check confirms John's plan covers urgent care visits, but he has a $20 copay. The office informs John upfront about the copay so he can be prepared.

Benefits of Verification:

1. Fewer claim denials (insurance refusing to pay) due to errors.
2. Improved cash flow for healthcare providers.
3. No unexpected medical bills for patients.
4. By taking a few minutes to verify eligibility, everyone involved in healthcare can have a smoother experience.
5. Improves RCM efficiency.
6. Clarifies financial responsibility for both patient and provider

Outcomes of Eligibility Checks

A patient is either eligible or ineligible, after every eligibility check. A patient is eligible if he/she has insurance coverage and is able to receive the specified service/a specific service(s), and is ineligible if he/she has no insurance coverage, and is disallowed from receiving a specific/specified service(s).

It is always important when checking a patient’s eligibility, to select the appropriate benefit and service type.