Medical Insurance Verification Process

In these trying economic times, the survival of physician practices depends on appropriate reimbursement for services rendered. A physician has to treat patients enrolled in different types of plans offered by health insurance companies.  Claim denials are the bane of a medical practice and though the reasons may vary, many no-pays and delays occur simply because medical insurance verification process was at fault. It is very important for that physicians verify a patient’s insurance coverage before providing treatment. Only proper patient eligibility verification can ensure deserved reimbursement for services provided and prevent denials by the insurer. Here are the important steps involved in the verification process.

Update Practice Management Database

The patient’s demographic details and health insurance coverage information should be entered or updated correctly in the practice management database correctly. In addition to the patient’s name, address, policy ID, and electronic payer ID number, the insurer’s contact information should be entered so that the company can be contacted for verification.

Patient Eligibility Verification Procedure

Patient benefits can be verified by calling up the health insurance company and enquiring if the patient is eligible for the service and/or the procedure. The health insurer’s contract should be carefully reviewed to assure that the physician’s practice meets the health insurer’s verification of a patient’s benefit coverage. It is important to know if the patient was covered by the insurance plan when medical treatment was first sought.

During this process, all the details regarding the patients’ health insurance policy are collected and verified such as the type of policy, policy limitations and exclusions, policy effective date and the policy status (whether active or inactive). Information verified during the insurance benefit verification process includes co-pays, co-insurance, deductibles, start date of deductible period, claims mailing address, billing and coding requirements for type of claim, out-of-network benefits, and more.

Insurance companies generally pay for covered services if they are medically necessary. When a physician decides that a certain treatment is medically necessary for a patient, the physician cannot be sure that the patient’s health insurance will provide reimbursement for the service or procedure. Therefore, physicians should closely examine the health insurer’s contract to understand exactly the patient’s health insurance benefits. This determination involves pre-authorization, pre-certification, and pre-determination:
  • Pre-authorization – Practices can obtain pre-authorization by calling up the insurance companies. This is necessary to ensure that the physician meets the medical necessity guidelines of the company. Pre-authorizations are generally required for specific in-office and/or outpatient diagnostic tests and surgical procedures.
  • Pre-certification – Pre-certification requirement verification involves checking whether the proposed service or procedure is covered in the patient’s insurance contract.

  • Pre-determination – This involves getting written confirmation from the insurance provider that a particular service or procedure is covered in patient’s benefit coverage. The health insurance company usually specifies in advance as to which procedures need prior determination. The pre-determination letter sent to the insurer should be accompanied by copies of the patient’s medical records including test results and progress notes.
Group coverage, dependant coverage, status changes, and special enrollment also need to be verified. It is very important to perform insurance eligibility verification every time a service is provided as insurer rules keep changing.

Professional medical billing companies offer comprehensive insurance verification as part of their overall services. With a efficient outsourcing company handling their patient benefit verification, physicians can focus better on their core tasks and worry less about compliance with health insurers’ rules on coverage. A professional insurance verification company can ensure error-free verification of coverage on all primary and secondary insurers in minimum turnaround time.


  1. Nice post about the medical insurance verification process.i have accepted that two things such as, Pre-authorizations are commonly required for specific in-office or outpatient diagnostic tests and surgical procedures and also pre-certification which is involves check whether the proposed Medical Services of Coding or procedure is covered in the patient’s insurance contract.

  2. Pacific BPO provides end to end bpo outsourcing solutions for medical healthcare including medical coding in India.

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