In the U.S., approximately 200 million medical claims are denied each day, with around 1 in 7 claims being rejected. Alarmingly, 27% of these denials occur due to patient registration and eligibility issues, creating significant challenges for healthcare providers. Each denied claim can cost healthcare practices an average of $25 to resolve, impacting their cash flow and overall revenue cycle management (RCM).
Incorrect insurance eligibility verification not only increases operational costs but also delays revenue collection, disrupting the entire billing process. For healthcare providers, using a reliable and efficient insurance verification method is essential to avoid denials, streamline billing, and improve financial performance.
This guide from HBH Solutions explores the best practices for verifying Medicare eligibility, helping you manage claims more effectively and improve your bottom line.
What is Medicare Coverage?
Medicare is a federal health insurance program that was created in 1965. It provides healthcare coverage primarily to individuals aged 65 and older, regardless of their income, work history, or health condition. Managed by the Centers for Medicare and Medicaid Services (CMS), Medicare is structured to assist beneficiaries with healthcare expenses but does not cover all medical costs. Beneficiaries are still responsible for out-of-pocket expenses like deductibles, copayments, and services not covered by Medicare.
Medicare is divided into four parts:
- Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facilities, hospice, and some home healthcare services.
- Part B (Medical Insurance): Covers doctor visits, outpatient care, medical supplies, and preventive services not included under Part A.
- Part C (Medicare Advantage): An alternative to Original Medicare, allowing beneficiaries to receive all healthcare services through a single provider.
- Part D (Prescription Drug Coverage): Helps cover the costs of prescription medications.
Why Verifying Medicare Eligibility Matters
Ensuring that your patient’s Medicare eligibility is verified before services are rendered is critical for maintaining the financial health of your practice. Failing to verify coverage can result in claim denials, reduced cash flow, and unnecessary administrative burdens. Manual eligibility verification can cost providers up to two patient visits per day, which translates to approximately $6,000 annually. Switching to electronic verification methods can save time and money, ensuring a smoother revenue cycle.
Verifying Medicare eligibility upfront offers several benefits:
- Faster Claim Approvals: Checking eligibility before services are rendered reduces the likelihood of claim denials, speeding up the payment process and improving cash flow.
- Clear Understanding of Patient Costs: It allows you to know the patient’s copays, deductibles, and out-of-pocket expenses before treatment, making it easier to collect payments on time.
- Increased Patient Satisfaction: Providing patients with a clear understanding of their insurance coverage in advance minimizes billing disputes and enhances their overall experience.
- Steady Cash Flow: Preventing payment delays by verifying eligibility early helps maintain a steady revenue stream.
Methods for Verifying Medicare Eligibility
Here are six reliable methods for checking Medicare eligibility:
1. Using HBH Solutions Medicare Verification
Visit the HBH Solutions website and submit a request by filling in your details (name, email, phone number, and monthly billing). A support representative will reach out to assist with verifying the patient’s Medicare coverage. Alternatively, you can call HBH Solutions at (469) 294-9654 for direct assistance.
2. Secure Provider Online Tool (SPOT)
The SPOT tool allows providers to verify patient eligibility and claims status online, 24/7. It provides comprehensive information about Part A and Part B coverage, deductibles, therapy caps, inpatient care, and Medicare Secondary Payer (MSP) status. By entering the patient’s details (name, Medicare Beneficiary ID, date of birth, and service date), you can check the full eligibility status for up to a year.
3. Interactive Voice Response (IVR) System
The IVR system allows Medicare providers to verify eligibility over the phone. Providers can access eligibility information, primary care doctor details, and claim statuses for Medicare Parts A and B. IVR systems are available Monday to Saturday, with customer service support for more complex inquiries.
4. Medicare Administrative Contractor (MAC) Online Portals
MACs manage Medicare claims and offer online portals for verifying beneficiary eligibility. After registering with your local MAC, you can check eligibility by entering the beneficiary’s Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI), along with their name and date of birth.
5. Phone-Based MAC Verification
MACs also offer phone-based verification, available 24/7. Providers can authenticate themselves using their National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), and Tax Identification Number (TIN) before entering the patient’s HICN or MBI for eligibility verification.
6. HIPAA Eligibility Transaction System (HETS)
HETS allows providers to verify eligibility through a HIPAA-compliant electronic transaction. After submitting a HETS 270 request with the patient’s MBI, name, and date of birth, providers receive a 271 response containing Part A and B coverage, lifetime reserve days, and skilled nursing facility entitlements. HETS integration with billing software is especially useful for large practices.
Conclusion
For small healthcare practices, verifying Medicare eligibility upfront is essential for reducing claim denials, ensuring timely payments, and maintaining a healthy cash flow. By leveraging the methods outlined above, practices can streamline their billing processes and improve their revenue cycle management.
HBH Solutions is committed to helping healthcare providers manage these challenges by offering expert medical billing and eligibility verification services. With our support, you can focus on providing exceptional patient care while we handle the complexities of insurance billing.