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Pump up your Eligibility and Verification Strategy

With today’s constantly changing and evolving insurance rules and regulations, it is imperative to pay more attention to eligibility and benefits verification. Accurate insurance verification ensures a greater number of clean claims, which speeds up the clearance and shortens the billing cycle. Other complex processes involved in RCM can deflect the attention of the practice, leading to claim denials. You can collect information with greater accuracy if you have the eligibility and benefit verification process in order. This means that providers must understand the insurance verification procedure and its significance to the dental care sector. This could also mean that mistakes made in carrying out effective insurance verification or in submitting a claim for a procedure that the patient’s insurance carrier does not cover or that is performed by providers who work outside the employee’s health insurance provider network could result in the patient feeling financially vulnerable, anxious, and frustrated.

Practices may face a lot of snags while dealing with eligibility and benefits verification, which could lead to claim denials or rejections.

Some common mistakes include:

  • Typos or other minuscule errors in the information collected from patients
  • Insufficient or incomplete patient information
  • Expired coverage
  • Services that are not covered
  • Services that require prior authorization or referral
  • Out-of-network coverage
  • Inactive insurance policies
  • Neglecting to ask about a secondary policy

So, how can you improve your eligibility and verification process?

Perform an eligibility and benefit verification prior to the service

To receive maximum payments for the services rendered, practices needs to verify the patient’s eligibility before every patient visit. It is, however, one of the most neglected or delayed steps, which often leads to claim denials. The time leverage aids you in identifying and filling in missing or insufficient information, if there is any. The eligibility and benefit verification processes include data management, analysis, and recording skills, which cannot be performed properly if carried out at the last possible moment. This means that on-time eligibility and benefit verification help you reduce claim rejections and denials to a great extent. 

Crosscheck or review the data collected

The patient information collected, including the dental care and insurance data, need to be reviewed carefully in order to identify any errors, missing information, or the validity of the data collected. This information collected is the foundation of a dental claim and helps with proper eligibility verification. An error that could seem trifling can cause claim denials. Extra care must be taken while transcribing information into the patient records. Rushing through benefit verification without reviewing it again may result in days or weeks of payment delays or a claim going unpaid entirely, both of which can be problematic for any practice.

Always have supporting documentation for the information collected

Have sufficient proof of the collected data for future reference and in case of emergencies. These could provide swift reference and could help to avoid any errors while putting in the data. This could make your eligibility and verification processes faster and easier and save on time.

Analyzing and calculating patient’s responsibility

Determine in advance what the patient may be required to spend out-of-pocket and how much the insurance company is likely to reimburse. Some plans might have restrictions on the cost of each visit or the frequency and duration of the services that must be provided. Benefit verifications checks need to be performed to examine if any benefit limit has been stated, indicating the number of benefits available for the patient.  Patient responsibilities such as deductibles, copayments, and co-insurance must be communicated to patients in advance for greater transparency and trust.

Have an insurance verification checklist

Make sure that you ask pertinent questions for eligibility and benefits verification. There are chances that critical information may be left out. A well-organized checklist could serve greatly for this very purpose. It will help you to have an organized and accurate eligibility and benefit verification process and can reduce the chances of the practice missing out on important pieces of information or data. Some important information to be included in the checklist are:

  • Patient benefits
  • Co-pays
  • Deductibles
  • Status of patient policy
  • Policy effective and lapse dates
  • Type of plan and coverage details
  • Services under the exclusion list of policy
  • Claims mailing address
  • The possibility of referrals and pre-authorizations being required
  • Life-time maximum

Maintain regular contact with the patients as well as the insurance providers

Keep in regular contact with your patients as well as the insurance provider in case you need any additional information or clarity on any existing information. Do not hesitate to initiate the conversation, as this could greatly improve the efficiency and accuracy of your benefit verification process. This could also help in creating a bond with your patients, thereby earning their trust.

Identifying pre-authorization needs

Checking for pre-authorization requirements before starting the treatment is an important part of eligibility and benefit verification, as there are several insurance companies that require pre-authorization for certain procedures.  Checking for and receiving pre-authorization ahead of time in such cases can significantly speed up your payment process and reduce the number of denied claims.

Partner with a reliable RCM service provider

Handling eligibility and benefit verification and other important RCM processes along with patient experience and treatment can be an added workload for your practice. It could significantly eat into your business hours and could leave you and your staff exhausted. With a dental revenue cycle management service provider by your side, your practice will be free of the complexities of the revenue cycle. This will provide you with the time to focus your attention on the more important tasks of the practice. Which, of course, could help improve the overall revenue cycle, efficiency, and growth of your practice.

Many practices and patients are unaware or confused about the eligibility and benefits verification process and often make mistakes. Following through on a proper and well-managed eligibility and benefits verification process can undeniably have a huge impact on your practice, improving its revenue cycle and revenue. It also leads to a better patient experience as well as improved patient satisfaction. Eligibility and verification is the first step to your revenue cycle and mistakes made at this stage could mean starting over on the entire process. To avoid any costly mistakes and to maintain the financial well-being of your practice, a healthy and smooth eligibility and benefits verification process is indispensable.

Errors In Your Eligibility and Benefits Verification

The dental billing revenue cycle is a challenging but essential procedure for a consistent and steady revenue stream. It is one of the first steps in the revenue cycle management process; which means that any mistakes or errors made at this level can lead to complications and have a significant impact on the entire revenue cycle. Inaccurate insurance eligibility and benefits verification can lead to delayed payments, denied claims and even nonpayment. 

Errors made during this process can cost your practice more money than you might think. Most claim denials occur, directly or indirectly, due to insufficient or inaccurate information gathered, which is, basically, eligibility and benefits verification. The first step to reducing the number of claim denials is to establish an efficient eligibility and benefits verification process. 

Here are some of the common eligibility and verification errors:

Inaccurate patient information

Verification is done to guarantee that your patients receive accurate billing for the services rendered. At times, errors can occur at this step; one of the most common errors being inaccurate patient information. This may happen for a lot of reasons, including a mix-up in the patient’s dental records. Something as simple as a middle name not being mentioned can lead to denials. Avoiding this problem will require that information is gathered diligently. Patients and the insurance providers must be contacted directly in case additional information is required. This also ensures that the data gathered is up to date.

Inactive insurance policy

Inactive insurance policies could be another reason for claim denials. In their hurry to submit claims, a lot of practices fail to check if the policies were active during the date of service. Information like the address for the submission of claims become invalid if the plan itself has become inactive. Contacting the insurer prior to providing the service is the best way to ensure that claims are not billed to inactive policies. Remember to verify the patient’s eligibility at the time of the visit before performing the treatment to make sure that the policy you are billing on is current. 

Failure to properly check the coverage

Eligibility and Verifications is not a process that should be done once in a year. There could be several changes that are made on policies by insurers within a plan year. Practices often make the common mistake of not properly checking the insurance coverage of their patients. This again happens for a lot of reasons, but is often due to incorrect or outdated information. This could also lead to frustrated patients, as they would have to pay out of their pockets. It is always better to contact the insurance provider and get confirmation in case there are any doubts about patient coverage. It is also important to keep up with the changes to insurance plans. If a patient has a new plan or their coverage has changed, be sure to verify that the coverage for the services provided is still in place. 

Duplicate data

Another common mistake that practices make in eligibility and benefits verification is to duplicate data entry. Duplicate data can lead to delays in billing and payment, and can also cause confusion for both patients and your staff. This may seem like a simple mistake but it can happen very easily, leading to claim denials. When entering patient information into the system, make sure to check for duplicates and correct them before moving on.

Missing documentation

A claim that doesn’t have the necessary documentation would most probably get rejected. The only way to rectify this situation would be to resubmit the claim with the proper and complete documentation. This can delay payment collection and make your patients irritated and frustrated. Information regarding documentation for each procedure needs to be collected during the eligibility and verifications process in order to avoid this problem. 

Neglecting to ask about a secondary policy

Some patients may have more than one active dental insurance plan. They are usually identified as the primary and the secondary plans. In such cases, claims should be billed initially to the primary insurance provider. Claims could get denied if the claim is billed to the secondary insurance provider. The practice staff must inquire about any secondary coverage during their eligibility checks to guarantee accurate claim filing. 

Remember, eligibility and benefits verification errors can cost your practice a lot of money. There are simple things you can do to help reduce the number of errors on your claims. Firstly, make sure that you identify and understand the eligibility and benefit requirements for the services provided to each patient. Secondly, verify that the patient’s policy meets the requirements before you provide the treatment. This can help your practice reduce the number of errors on your claims and save money in the long run.

Importance of Eligibility & Benefits Verification

Verifying insurance eligibility and benefits is one of the first and most important steps in the dental RCM process. It is the process of confirming a patient’s active coverage and eligibility with an insurance company. A majority of Americans are insured. As a result, it becomes critical to verify their insurance eligibility before providing any treatment or dental care. Proper eligibility and benefits verification provides the practice with a clear view of a patient’s insurance coverage, benefits and payment obligations so that they can submit clean claims without any mistakes. With today’s changing and increasingly complex insurance payment processes, it becomes necessary to pay careful attention to the verification of coverage, benefits, co-payments, and unpaid deductibles. Most claim denials occur because of errors in eligibility checks, while every successful insurance payment is largely dependent on successful eligibility and benefits verification.

Processes Involved in Eligibility and Benefits Verification

1. Patient Scheduling and Enrollment:

The first step in eligibility and benefits verification includes scheduling patient appointments. This can be done through phone calls, text messages, or online booking methods. During the appointments, the patient’s information as well as patient health details are to be collected. Essential information such as patient name, phone number, address, medical history, diagnosis and more is to be collected carefully without any mistakes.  

2. Patient Insurance Verification:

It is one of the most important processes, where the patient details such as insurance coverage, benefits and more are verified and cross checked. It is usually done before the patient’s appointment. While carrying out the eligibility and benefits verification on a patient ensure that the information obtained is correct and up-to-date. Any error in this information can lead to denial of claims. With the frequently changing insurance processes, it is important to remain up-to-date so that you don’t make any mistakes. Check through the information and claims thoroughly as many times as possible, because denied claims can be a huge hassle.

3. Collecting additional information from the patients and the insurance company: 

Collecting accurate information is key to efficient eligibility and benefits verification. If any doubt arises about the patient information or insurance coverage details, make sure to contact the patient or the insurance provider if needed. It can be through a simple text or call. It could help in clearing doubts and staying up to date, thereby producing clean claims without any errors. In case of doubts regarding the insurance coverage, you can always contact the insurance provider for more clarity. But make sure you always collect precise information.

4. Updating the RCM System: 

The revenue cycle management system needs to be updated with the collected patient information and insurance coverage details. Make sure to update it correctly without any errors. This is the last stage in eligibility and benefits verification and therefore must be given careful attention.

Benefits of Eligibility and Benefits Verification

1. Submission of Clean Claims

Eligibility and benefits verification help you submit error free clean claims. It helps eliminate all errors in insurance claims before submitting them. The various patient information and insurance coverage details are cross checked before updating. This helps in avoiding any errors that may occur in patient information and insurance details. This makes the whole payment process easier and quicker.

2. Lower Claim Denials: 

Since all the errors are rectified during the eligibility and benefits verification stage itself, there is only a very low chance of claim denials. Submission of clean claims reduces the rate of claim denial and increases the claim acceptance rate. The complicated task of reworking and resubmitting denied claims can thus be avoided, making the payment process a lot easier.

3. Increase in Cash Flow: 

With an increased claim acceptance rate and a low denial rate, the revenue of the practice increases significantly.  Consistent and accurate eligibility verification is important for the consistency in the cash flow in a dental practice. Any error in this can impact the overall revenue of the practice. In cases where the policies do not cover the dental services or have expired, eligibility and benefits verification protects the practice from any impact on revenue and improve the overall cash flow.

4. Increased Patient Satisfaction:

Patients are the main priority in any practice, and eligibility and benefits verification help in providing your patients with quality services and giving them maximum satisfaction. Efficient eligibility and benefits verification enables you to be transparent with your patient through open communication, thereby earning their trust. It will also inform the patients about their responsibilities prior to their appointment so that they can come to the appointment with proper payment preparation. This gives them a sense of security and satisfaction and would make them want to continue service with you.


Failure to carry out proper eligibility and benefits verification can have a huge negative impact on the overall functioning of your practice. It affects almost all aspects, including cash flow, patient care and experience, insurance payment and dental billing and more. Any mistake in the eligibility and benefits verification process can lead to an increase in claim denials, a complex process of rework and resubmission, delays in patient care, which impacts the patient experience and satisfaction, and increased payment debts. In fact, it is very important for practices as well as patients to understand the eligibility and benefits verification process and its importance in facilitating fast and easy insurance payment. But with the changing insurance rules and policies, it becomes really difficult for the practice as well as the patients to stay on top of these requirements. Not just that, managing the insurance payment processes, including eligibility and benefits verification, along with patient care and other needs, can prove to be a really laborious job, disturbing the complete functioning of the dental practice. Therefore, most people nowadays opt for an RCM service provider. They help you manage all aspects of your revenue cycles so that you can provide your complete attention to patient care and experience.

A dental RCM service provider helps you stay up to date with the changing dental insurance rules and regulations in insurance payment so that you can give your undivided full attention to patient care, thereby increasing patient satisfaction. They interact with the practice as well as the insurance company, handle the paperwork, and verify patient information, thereby improving the revenue cycle and maximizing payment. They can do the work with maximum efficiency and save the practice and its staff extra time, effort and energy. An RCM service provider could be the ideal solution for managing the complex tasks of eligibility and benefits verification and insurance payment.