Patient Eligibility Checks – The Proactive Provider Is Doing Them

In Uncategorized on August 22, 2013 at 8:44 pm

Pursuant to 5010 requirements (the regulatory requirements attendant to the electronic submission and processing of your claims), as of January 1, 2013 all payers were supposed to have been officially obligated to offer “real time eligibility.”  What this means to your practice is that if you were to submit a patient eligibility information request to a payer to confirm that that patient is in fact covered for his/her upcoming appointment, then that payer has 20 seconds in which to respond to that request.  Twenty seconds – that is the new standard, as of January 1, 2013. 

As anyone who has performed an eligibility check well knows, the eligibility information received from the carrier varies by carrier.  Some provide only a yes or no response to the question of eligibility; others may provider the co-pay amount, the amount remaining on co-pay, eligibility for ancillary services (optical, dental, mental health, DME, etc…).  And because of this diversity of response, the helpfulness of the information varies as well.  In the coming years, this data is anticipated to be legislatively standardized as well, so that all carriers are providing the same information to eligibility inquiries.

Now, while the regulation currently places this imposition on the carriers, and there is no penalty to providers for NOT seeking eligibility information, the practical implication to the practice is that the standard/duty of care regarding eligibility may gradually shift from the patient to the provider….  What once used to be the onus of the patient (to ensure eligibility, or be responsible for payment in full if not eligible), may become that of the provider…  food for thought.

As always, please feel free to contact M.E.D.I.C., Inc. if you have any questions regarding eligibility issues.


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