Health insurance is a key element to ensure the well-being of an individual. Especially with the advent of the coronavirus pandemic, the workload of health sector companies has increased exponentially.
Health insurance companies have evolved to meet the challenges of increased demands but the rise in denial rates is still a daunting task to deal with. Patient eligibility verification services come in handy to streamline the overall process and increase its efficiency.
Reasons for claim denials in health insurance
A robust healthcare system is essential not just for individuals but for the economy of a country. The service that health insurance companies provide is key to the smooth running of the healthcare system in society. But, another truth is the operational & technical faults leading to the denial of claims. Some of the common reasons for claim denial are:
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Documental faults
Improper verification and documental rush-ups, which many times lead to claim rejections. A simple mistake in the name, like Shaun spelled as Sean, will get an insurance bill spurned. Other than this, a medical practitioner’s office may also error in the record ending in similar results.
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Missed key detail
If the claim application or pre-authorization should document all the required details. Missing out on any piece of information about the treatment will lower the chances of claim approval. For instance, if the patient applies for kidney tests and the practitioner’s office fails to document the need for diagnosis.
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An uncovered health service
It is a very common denial reason when the claimant applies for a treatment not listed in the insurance provider’s coverage plan.
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The claimant jumped an insurer’s rule
Policyholders should be attentive to the diseases covered in the plan, treatment network, rules and billing methods, etc.
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Insurers suggesting cheaper treatment
Sometimes Insurance providers may deny a claim by suggesting cheaper options for the treatment. The policyholder may have failed to explain the reason for opting for the expensive medical procedure, it may be required but the claim would be denied in the case.
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Insurance provider’s network
Being unaware of the treatment network of insurers, patients often jump out of the circle, which also results in rejection. As a health coverage provider, you need to explain the structure of your treatment network to the clients, along with the consequences of failing to comply with the rules.
| Claim denial rates can be reduced by putting in place a robust verification and pre-authorization system. Try SunTec India’s services mail us your requirements, at info@suntecindia.com |
The need for insurance verification and pre-authorization
As per the analysis of Harmony Healthcare, which surveyed more than 130 hospitals, the average denial rate is between 6% to 13%. The surveyor denoted 10% as the danger zone, and it was found that many insurers are nearing it.
Insurance verification and pre-authorization services can fill this operational gap through the use of technology and skills.
Insurance eligibility verification services are required as:
- It was estimated that most of the claims were denied due to manual errors in documenting facts.
- Medical practitioners’ offices often made improper recordings which resulted in denial of pre-authorization.
- The insured individuals could not understand the coverage plan and rights until it got too late.
- It was found that almost 90% of claim denials could be rectified by the use of insurance verification and pre-authorization services.
- It reduces the number of claim re-submissions and appeals. Saving time and money for claimants.
- It reduces operational costs for insurance providers.
- Better client satisfaction and improved cash flow for companies.
Insurance verification: Things to remember
As an insurance provider, the following simple measures can reduce claim rejections:
- Verification of factual documents with uttermost care, like:
- Insurance name, phone numbers, and address of the claimant
- Insurance ID and group number
- Name of the insured
- Relevant dates of the policy
- Make sure the Insurance covers the procedure diagnosis or service to be provided
- Coverage’s life
- Requirement of referral, pre-authorization certificate
- The payment details
- Ensure that accurate information is recorded in the patient’s medical file
- Follow-up with the patient wherever needed
The job of patient eligibility verification services
Claim Denial Statistics in America
Source – Centre for Medicare and Medicaid Services (CMS) |
The major tasks of a patient eligibility verification service include:
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Health insurance document review
The analysis and verification of documents provided by the organization. Compilation of documents and file management as per insurance provider’s need.
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Patient Follow-up
Documents are reverified with the patient, and all missing and incorrect information is rectified as noted. This ensures that all facts and findings are double-checked before the final submission.
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Scrutiny of Insurance verification
Insurance E&B and insurance coverage details are verified with primary and secondary payers. Patients are updated with records of co-insurance, copay, deductibles, PCP, Name matching, in-network, and out-of-network benefits.
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Final Claim submissions
Clients are given conclusive results. Key documents such as – member id, group id, insurance coverage dates, copayment information, etc.
SunTec India’s exemplary insurance eligibility verification service
Insurance eligibility verification is crucial for the efficiency of a health coverage plan. Missing or incomplete details provided by policyholders initially conclude in rejection of the claim later. The manual errors by hospital or administrative staff are another reason for these denials.
Some of the unique features of our Insurance verification and pre-authorization are:
- Insurance data security
- Accurate verification services
- Financially viable solutions
- Use of the latest medical billing technology &
- Quick turnaround time
- Ease of scalability
- The highly skilled medical billing team
- Experience healthcare professionals
| Our insurance verification and pre-authorization services are cost-effective, time-saving, and fulfilling for clients.
Try SunTec India’s Insurance verification and pre-authorization services to streamline your healthcare process, contact info@suntecindia.com |
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