Top 6 challenges of insurance verification

How well does your practice navigate these common obstacles of insurance validation?

What do 92% of Americans have in common? They all have some form of health insurance coverage, whether it’s through the government or from one of hundreds of commercial payers across the country.¹ In order to prevent delays in treatment, avoid denied claims, and get reimbursed promptly, it’s crucial to have your insurance verification capabilities buttoned up.

The process of verifying patient coverage isn’t without its challenges. How well you manage them can have a significant impact on care delivery, financial performance, and even your success with value-based care contracts. Let’s have a look at some of the most common challenges with insurance validation and how your practice can overcome them.

1. Incorrect insurance information from patients

Billing the right insurance plan for your patient is complex, and patients may accidentally make it worse by providing the wrong information. Your practice may have outdated insurance on file for a patient, or a family member may be added to or removed from coverage without your knowledge. With the innumerable variations of health plans available, a patient may know the name of their insurance company but misremember the specific plan they’re enrolled in. Because people can make mistakes, the verification of insurance coverage deserves your attention.

2. Not knowing which health plan to bill

It's also possible for a patient to legitimately have more than one insurance plan in effect. This can happen when, for instance, a recent graduate obtains insurance through a new job but is still covered on a parent’s plan, or a patient has purchased a private plan to supplement Medicare benefits. In these cases, it’s on the practice to verify which insurance is the primary payer. Payers want to prevent their members from “double-dipping” or being reimbursed twice for the same care, so they communicate with one another according to their Coordination of Benefits policies to see which insurance plan on file takes precedence. Determining which payer takes the lead is crucial to avoid denied claims.

3. Data entry errors introduced at the practice

Although the patient may present a valid, active insurance plan to the practice, the staff entering information into the practice’s medical billing system can inadvertently make mistakes. Incorrect details such as a misspelled name, a mistyped birthdate, or the wrong plan selected from a drop-down menu can be sufficient cause for a health plan to reject a claim. Leaving a field blank can also lead to a denied claim.

4. Hundreds of payers, each with their own requirements

As of 2023, more than 900 health insurance companies were providing medical coverage in the U.S.² Verifying patient coverage at each one requires knowing how that payer handles insurance validation inquiries. Even when a practice only works with a small subset of payers, it still poses a huge administrative problem for practice staff to solve for every patient encounter. 

Patients understandably want to know what exactly their insurance entitles them to receive, ideally before they consent to care.

5. Lack of practice staff or resources to manage the workload

Managing insurance eligibility verification is just one indispensable task among hundreds at a medical practice. The practice may simply not have the staff to stay on top of the work, which can soon snowball and become a drag on billing efficiency. When claims aren’t submitted promptly, days in accounts receivable can stretch on and on.

6. Being unable to manage patients’ expectations

One challenge of insurance validation is helping patients find out whether a procedure will be covered, whether it requires prior authorization, what their out-of-pocket costs will be, and so forth. Patients understandably want to know what exactly their insurance on file entitles them to receive, ideally before they consent to care. Without transparency into their eligibility, it’s hard to help the patient manage their expectations, their care, and their budgets.

The importance of optimizing insurance validation

When insurance verification is running smoothly, it supports virtually every aspect of your practice.

• It’s good for clinical outcomes. Knowing ahead of time that a procedure, medication, or test will be covered helps clinicians deliver care promptly.
• It’s good for financial performance. Insurance verification is directly connected to your practice’s financial health because it contributes to your ability to submit clean claims and be reimbursed in a timely fashion. As reported in Physicians Practice, almost 20% of claims are denied, rejected, or underpaid; and as many as 60% of returned claims are never resubmitted.³ Avoiding denied claims by verifying eligibility helps you access the reimbursement you’re owed.
• It’s good for staff efficiency and satisfaction. Optimizing insurance verification includes ensuring that as much work as possible can be automated and conducted error-free. Doing so helps you move repetitive administrative tasks off your staff’s plates, freeing them to take on other, higher-value work for the practice.
• It's good for your patients. When patient eligibility verification works well, you’re able to help keep patients informed about their coverage and their anticipated costs. Being transparent and helping patients manage their expectations helps to establish trust in you and your practice, and empowers the patient to make decisions about their care.
• It's good for value-based care. For practices participating in value-based care contracts through CMS or private payers, verifying patient coverage matters from both a financial and a clinical standpoint. Value-based care payer contracts have care gaps to close, as well as value tasks to complete. Because value-based care is about improving the quality of care while managing costs, both you and the payer have a vested interest in ensuring that the right level of care is being delivered.

Curing the complexity of insurance verification with athenaOne® technology

The athenaOne all-in-one EHR, practice & revenue cycle management, and patient engagement solution lightens the workload of insurance eligibility verification for practices. We’ve built in technology that takes on administrative burden, reduces errors, and forges the necessary connections to payers that help the entire process run more smoothly.

• The AI-powered automated insurance selection tool built into athenaOne uses a machine learning model to process a photo of the patient’s insurance card. It analyzes the photo, accurately captures the necessary information, and matches it to patient data to recommend the correct insurance. This saves time on manual work and reduces the chance of data entry errors, which helps to decrease claim denials so your practice can get reimbursed more quickly.
• athenaOne uses automated eligibility check to find a patient’s insurance status with payers three days before a scheduled appointment. To facilitate this background process, we maintain electronic eligibility interfaces with numerous payers across the country. Eligibility is also checked when insurance information has been updated in the patient record, and the practice can opt to check eligibility at any time on demand. athenaOne shows an alert at check-in if the patient’s status is “unverified” or “ineligible,” so the check-in staff can address the issue with the patient. According to Tina Kelley, Director of Operations at Mountain View Medical Center, “Automating insurance selection removes guesswork for our staff, ensures accuracy, decreases denials, and helps us get paid faster, which is essential for our growing practice.”
• With pre-established connections to payers across the healthcare ecosystem, athenaOne facilitates the smooth flow of data for eligibility checks and claim submission. athenaOne takes the burden of establishing and maintaining links to payers off customers’ plates so they can focus on care. Our customers let us know which additional payers we should connect to, saving them the effort and cost of creating and sustaining those links on their own.

Interested in learning more about athenaOne’s approach to patient eligibility verification? Get in touch and request your demo.