Transforming Insurance Verification with Technology-Driven Solutions

It’s Monday and you’ve just returned to work after the weekend. You open your mail and see that over 50 verification requests are waiting for you. It’ll take you at least 20 minutes to validate each one, consuming time and energy that could be better spent elsewhere.

Traditionally, verifying insurance coverage has been a daunting process, requiring multiple calls to insurance carriers or sending numerous emails or faxes to check the validity, benefits, and coverage extent of the policy. However, this process has been fraught with human errors due to a variety of factors, ranging from the overwhelming number of patients to frequent changes in policies.

This used to be a common scenario in the healthcare and insurance industries where resources and time were spent on repetitive tasks. Recognizing that nobody wants to be stuck in a cycle of long phone calls, back-and-forth emails, or navigating multiple online portals just to validate a policy, the past decade has seen the emergence of insuretech solutions that have simplified the challenge of coverage validation. These solutions not only streamline workflow but also prevent financial loss by optimizing reimbursements and eliminating denials or rejections through proper checks.

What is Modern Insurance Verification?

We’ve come a long way from basic online database portals where you can look up patient or policy coverage. Technological adoption has resulted in the development of software that automates the entire verification process while integrating with insurance core system platforms to enhance claims processing.

Insurance Verification Software is an automation tool that integrates with existing systems or payer databases to determine the validity of coverage, whether the policy covers required services, and if any deductible, prior authorization, secondary insurance, or copayment is applicable. This ensures that patients do not end up paying out of pocket and that medical professionals do not face bad debt due to denials.

Why Should Medical Insurance Verification Software Be a Part of Your Revenue Cycle?

The high cost of manual verification can significantly impact the organization in many ways and affect customer experiences. While these issues might seem minor at first, they can end up costing millions in the long run. Below are some aspects to consider to understand the importance of adopting verification software.

Time-Consuming Process: According to a 2022 CAQH Index report, the redundant task of verifying eligibility for each patient takes at least 14 minutes. In other words, if a claims processor has 20 verification requests, it could take about 4.6 hours to complete the task. Now imagine saving 4.6 hours of productivity simply by automating the verification process.

Administrative Burdens: The tedious process of verification can lead to stress and exhaustion. Human errors are unavoidable in repetitive tasks, a healthcare.gov survey shows that 1 in 5 claims are erroneous leading to denials or appeals. You wouldn’t want your competitors processing claims in seconds while you are stuck in a dreary cycle of eligibility verification, would you? Automating eligibility transactions not only eliminates errors but also prevents burnout and increases job satisfaction.

Financial Burdens: Manual verification will inevitably cause delays, potentially leading to backlogs and cash flow issues. AMA’s survey found that there are delayed or unpaid claims totaling $6.4 billion that are only 6 months or older. Real-time verification provides us with a clear picture of the entire policy coverage, benefit limits, and additional expenses like copays or deductibles. This ensures a smoother revenue cycle management by speeding up response times.

Denial Appeals Cost: Denials on claims can occur for various reasons, from patient registration and eligibility issues to human errors in coding and clinical validations. Research from the Kaiser Family Foundation shows that 90% of denials are actually preventable. While only a moderate percentage of denied claims are appealed, you have to go through the hassle of collecting the amount due. The expensive battle makes it a much-needed win.

Clean Claim Rates: Coverage eligibility validates the plan and benefits from various databases in real-time. This ensures that the required services are covered under the policy, ensuring reimbursement for any claims submitted. This practice promotes billing efficiency, ultimately increasing clean claim rates and enhancing operational effectiveness and cash flow.

Regulatory Compliance: Traditional verification methods using calls, emails, and spreadsheets, may compromise data or fail to comply with regulations like HIPPA, ACA, or any state-specific insurance compliance laws. Your legal team will have one less issue on their plate as insurance verification software is updated to comply with ever-changing regulations and insurance policies.

Fraud Detection and Prevention: Relying solely on insurance identity cards is inadequate, as policies may be updated or canceled, especially with the rise of identity theft. Overworked employees may struggle to detect fraudulent claims amidst the complexity of online portals, emails, and calls. CMS mentioned that $95 billion was spent on improper payments related to abuse or fraudulent claims.

Improved Customer Experience: Having a good understanding of a policy’s coverage and benefits ensures that customers do not have to pay out of pocket or leave providers unpaid. The transparency provided by verification checks helps avoid unexpected bills and clarifies financial responsibility.

Evidently the benefits provided by verification software are critical to ensure timely payments, avoid denials, and improve efficiency.

Factors to Consider When Evaluating the Right Software For You

Technical Integration Capabilities: The software should easily integrate with your existing systems, such as CRM, Billing software, or policy management. Additionally, it should be compatible with core systems and provide flexible database connectivity (including multiple EHR systems and practice management systems).

Automation and Scalability: The software should require minimal human intervention by offering data extraction features that can handle batch verification. A robust OCR should be included to process various document formats.

Customization: The software should allow for customization and tailoring workflow solutions to meet your organization’s specific needs. Ensuring improved efficiency should be the main goal of any verification

Vendor Support: The software implementation should be smooth with reliable and timely customer support. Evaluate the implementation timeframe, available training resources, and support provided during and after implementation.

Regulatory Compliance: The software should maintain compliance with HIPAA, ACA, and GDPR, offering proper access control options. Robust advanced encryption methods, such as Advanced Encryption Standard (AES) and Transport Layer Security (TLS), should be in place to ensure the safety and confidentiality of patient information.

Reporting and Analytics: The software should generate reports of policies, indicating any changes or updates. Data-driven analytics should be used to identify trends and patterns that can help optimize workflow.