Did you know that with proper verification of benefits (VOB), you can reduce denials related to eligibility and prior authorization? Moreover, you get clarity into the patient’s financial responsibility.
Wondering how? Because VOB in medical billing is an integral step that allows you to confirm a patient’s active insurance, specific coverage for services, and financial responsibility, like co-pays, deductibles, and pre-authorization rules.
This guide covers the process, challenges, and differences between benefits and eligibility verification. So, continue reading!
Benefit Verification Process in Medical Billing
The following are the steps involved:
Step 1: Collect Patient Information
The first step in the VOB process should be to collect patient information at the time of scheduling or registration. This includes patient demographics (name, DOB, contact), insurance details, and specific plan information.
Step 2: Collaborate with the Insurance Payer
Once you have all the details, it is time to connect with the insurance payer’s administrative and billing staff. The goal here is to verify benefits.
It may involve using the payer’s specific online portal or calling them directly.
Step 3: Verify Policy and Coverage Specifics
When the connection has been established, verify the following details:
- Check whether the patient’s policy status is active or not.
- Validate the patient’s coverage for the required care procedure.
- Understand the deductibles, co-pays, and co-insurance amounts.
- Ask if pre-authorization is needed for the specific medical service.
Step 4: Document the Process
You must document the entire benefit verification process in the patient’s medical record, including the estimated patient responsibility amount.
Step 5: Communicate with the Patient
The final step in the VOB process is to inform the patient about their financial responsibility and prior authorization requirements (if any). It is an integral step because it may help you collect applicable co-pays or deductibles upfront before rendering the service.
Key Verification of Benefits (VOB) Challenges
Discussed below are some of the major challenges related to benefit verification in medical billing:
The Data Mismatch Error
Manual data collection errors happen because patients often provide incomplete or outdated insurance details.
For instance, the patient switched jobs or the plan expired, but showed their old insurance card during check-in. If your staff is not trained to perform the benefit verification process immediately, it can lead to denials.
In other scenarios, the front-desk staff can also make data entry errors. Let’s say the staff entered the patient’s name as ‘Sarah Garcia-Lopez’, but the insurance record only shows ‘Sarah Garcia’. Since insurance payers use strict exact match algorithms, this clerical error will result in a ‘patient not found’ error despite having an active plan.
The result? This delays the reimbursement cycle as staff must call the payer to reconcile the name.
The Hidden Pre-Authorization Clause
Identifying if a service is covered is only a part of the verification of benefits in medical billing. Determining whether it requires pre-authorization is the second half and the hard part.
The reason? Payers frequently update their prior authorization lists without notifying healthcare providers.
For example, a cardiologist was conducting nuclear stress tests without pre-authorization from a specific payer for several years. However, the insurance payer changed the policy. As a result, the physician received multiple denials, straining their revenue cycle.
The Volatility of Real-Time Deductibles
Unfortunately, the deductible balances do not update across all systems in real time. As a result, it often becomes challenging to provide an accurate estimate of patient responsibility.
Picture a patient whom you have informed that their out-of-pocket cost for a cardiac scan is $400 after checking the VOB tool. However, in reality, their pharmacy claim from the previous night has been processed, meeting their deductible.
The impact? You overcollected from the patient, leading to a refund liability. This not only leads to an unnecessary administrative expense but also damages the patient’s trust.
Coordination of Benefits (COB) Conflicts
What happens when a patient has two active policies, but the primary insurance is not correctly designated in the system? Both payers will deny payment against the claim, each claiming the other should pay first.
Thus, it is integral that you identify primary insurance and secondary payer’s specific filing rules while performing VOB in medical billing.
Difference Between Eligibility & Benefit Verification
The table below offers an at-a-glance view of the key differences between benefit and eligibility verification:
| Differences | Benefit Verification | Eligibility Verification |
|---|---|---|
| Ask the Payer | Which specific services are covered and at what cost? | Is the patient’s insurance policy currently active? |
| Primary Focus | Coverage limits, patient responsibility, and rules. | Membership status and policy dates. |
| The Outcome | Estimate patients’ out-of-pocket costs and determine pre-authorization requirements. | Prevent denials for ‘patient not covered’. |
To summarize, insurance eligibility verification is the foundational step that the front-desk staff performs at the time of scheduling or during check-in. That is, it confirms the legal standing of the insurance contract.
Contrarily, VOB occurs after eligibility verification and unveils the specifics of the insurance plan to prevent financial surprises. These specifics include details such as patient responsibility, service-specific coverage, pre-authorization requirements, network status, and benefit limits.
Streamline VOB with MediBillMD
With that said, it is clear that benefit verification is an integral process in medical billing. If you take it for granted or do not perform it, denials become inevitable.
Most of the time, practices fail because their front-desk staff is already overburdened. In these circumstances, outsourcing insurance eligibility verification services to professionals, like MediBillMD, is a wise choice.
MediBillMD is a leading medical billing company that has been helping many practices by performing advanced eligibility checks and timely eligibility audits across 62+ specialties nationwide.
