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The Importance of Eligibility Verification and Pre-authorization


In medical billing terminology, eligibility verification, pre-authorization, prior authorization and pre-certification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.

Depending on what the patient’s coverage documents and the provider’s contract with the insurer specifies, neglecting to obtain pre-authorization can result in reduced reimbursements or lower benefits for the patient. If a provider neglects to obtain pre-authorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient.

GeBBS Healthcare Solutions, with our Eligibility Verification and Pre-Authorization services, specializes in next generation revenue cycle management to help increase cash flow and speed medical billing processes.

With today’s high-deductible insurance policies, insurance and eligibility verification are absolutely critical. Identifying patient responsibility upfront, prior to the visit, is critical to managing the receivables. In the absence of proper eligibility and benefit verification, countless downstream problems are created — delayed payments, reworks, decreased patient satisfaction, increased errors, and nonpayment.

A McKinsey Quarterly survey of retail healthcare consumers showed that 52 percent of consumers would pay from $200 to $500 or more by credit or debit card when they visit a physician, if an estimate was provided at the point of care.

To avoid these problems, GeBBS provides a remotely-hosted Centralized Eligibility Unit for hospitals, faculty practice plans, PMS/EMR vendors, and billing companies. The solution consists of GeBBS staff, technology, management and expertise that delivers high-quality, cost-effective patient insurance eligibility and related services.

GeBBS Eligibility Verification/Pre-authorization Services can:

  • Improve A/R cycles (reduce A/R days)
  • Increase cash collections by reducing write-offs and denials
  • Receive schedules from the hospital via EDI, email or fax
  • Verify coverage on all primary and secondary (if applicable) payers by utilizing sites like WebMD, payer web sites, interactive voice response systems, and phone calls to payers
  • Contact patients to get updated insurance information
  • Provide the clients with the results, which include eligibility and benefits information such as member ID, group ID, coverage end and start dates, co-pay information
  • Obtain pre-authorization number
  • Obtain referral from PCP
  • Enter/update patient demographics
  • Remind patient of POS collection requirements
  • Inform client if there is an issue with coverage or authorization
  • Process Medicaid enrollment

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