Medical insurance verification software: Types and advantages

Insurance eligibility and verification confirm a patient’s insurance plan. If coverage is not validated, it can lead to billing errors, payment delays, and lower revenue. Eligibility is considered to be the first stage of the verification process. During this stage, the medical staff determines if the patient’s insurance is active. Verification itself provides greater details about the patient’s benefits.

In this article, you will learn the essence of the medical verification process. Also, you will find out what software is used to manage this process and how custom solutions differ from commercial IT products. Besides, at the end of the post, you will get a four-step guide on getting a fully customizable solution for your needs.

The information below will be useful for medical practices, hospitals, and medical providers, as well as for software companies that search for technology partners overseas to build high-quality healthcare and insurtech solutions at a reasonable price.

What is medical insurance verification?

Hospitals, doctors’ offices, and other healthcare providers would like to know whether a patient is covered for care. Within the industry, this request is known as a real-time insurance benefits verification. An eligibility transaction just asks a question according to the patient’s insurance plan: “Is this patient eligible to receive care from the doctor?”

Until recently, accessing this information has been primarily a manual process. The provider’s staff would call the insurance company, send a fax, or log into multiple web portals in order to check for patients’ benefits. In the background of these manual processes, there exists an entire industry of third-party partners that pass data from one entity to another. Why is the healthcare industry is still processing important data manually? Over the last years, different software companies started creating technological solutions to solve this problem.

A step-by-step process to verify medical Insurance

To better understand what software solutions fit the needs of verification specialists, let’s see what steps they take to verify medical insurance:

1. Check if the patient’s records are accurate and up-to-date (name, date of birth, social security number, insurance ID, etc.)
2. Ask a patient to provide his/her original insurance card and ID photo
3. Ask insurance providers whether a patient is covered for care
4. Clarify which services are covered
5. Check the information about deductibles
6. Verify co-pays with a patient
7. Check if a patient has secondary insurance

What software is used by medical insurance verification specialists?

To automate the process of medical insurance verification, healthcare providers started using specialized software that typically provides the following features:

• Dashboards allow investigating coverage information and getting verification results automatically.
• Upcoming appointments allow checking eligibility options and whether they will be covered on the scheduled date.
• Alerts and notifications inform providers of any changes or charges that are not covered by the current patient’s plan.
• The pre-authorization feature allows for managing authorizations and informing the front office when a patient is out of authorization.
• The data scrubbing feature allows verification specialists to check the patient’s information for completeness, make changes in the information, etc.
• The calculating insurance payments feature allows for managing deductibles, co-pays, benefits coverage, and co-insurance.
• The reporting feature allows checking certain information for a certain period of time on a single screen.

Dental insurance verification software

Dental insurance verification works the same way as eligibility verification for any other type of insurance. Many dental practices in the United States lose their loyal patients due to inaccurate insurance verification submitted by their overburdened staff, which makes the practice look disorganized in the patient’s eyes.

Modern dental insurance verification software takes care of the complete insurance verification process so that dental practices can focus on delivering the best patient experience. The software verifies eligibility prior to patient appointments and provides regular updates regarding plan changes. Customers can discuss their benefits with the staff as soon as they come to their appointments.

With a custom solution in place, you can get a product that will be fully customizable as per your office’s exact requirements to ensure that your dental practice’s needs are completely met. Such solutions can free your staff from time-consuming tasks, maximize reimbursements, and minimize denials.

Related case study: Software for dental clinics

Why medical insurance verification software is important for medical practices?

As a part of the electronic health records (EHR) software package, eligibility verification solutions help medical practices with lots of problems related to insurance coverage. Usually, practices rely on front-office workers but forget to give them user-friendly tools to manage verification processes. The wrong choice of verification tools or even their absence can lead to overload and rejected claims.

By using electronic verification solutions, providers are able to reduce rejected claims and manage patients’ payment responsibility more effectively. With proper tools in place, medical practices can submit inquiries and get instant responses to patient data. These capabilities automate the entire process of verification, reduces manual and redundant tasks, save time, and cut administrative costs.

Outsource healthcare software development in case you need a unique custom solution at a reasonable cost.

Benefits of medical insurance verification software

An effective eligibility verification process can turn around and streamline the entire revenue cycle management. It boosts related workflow processes, making processes more autonomous, reliable, and convenient. Up-to-date software can help automate the eligibility verification procedure, cutting risks and costs.  

For instance, our developers create tailored medical insurance verification software that can turn your business around. Let’s review the main ones.  

Lower errors and higher staff productivity 

Insurance verification software upgrades the billing process. Automated patient data checks allow for the confirmation of information with an insurance system in real time. It’s a simple solution to avoid mistakes that could occur during manual entry. Reducing errors caused by the human factor makes the system faster and more reliable overall.  

Real-time policy verification cuts out errors related to expired and invalid policies. All checks take less time and can speed up the insurance procedure.  

The software integrated with EHR systems provides access to up-to-date information, minimizing the chances of information mismatch. A tailored EHR system helps to arrange verification within one platform without switching over several applications. 

Automated software considers insurance rules, regulations, and requirements. It checks compliance with them in advance. In case of any discrepancies, the system sends a notification to fix them immediately. 

The staff does not need to switch between systems. The process takes less time, and patient eligibility and coverage get faster confirmation. As a result, you can dedicate more time and attention to patient care and other duties. The workflow becomes more productive and cost-effective.  

Improved revenue cycle management 

Accurate insurance verification reduces claim denials caused by invalid or expired policies. Well-equipped software can determine patient coverage data in real time. Proper verification ensures proper billing. This whole process minimizes cases of underpayment or failed payment and reduces the rates of claim denials caused by eligibility issues. 

The software can help ensure the patient has all the required approvals before seeking insurance service. It can also help cut payment delays. Transparency in insurance coverage, costs, and payments is vital. The software makes the system simpler to grasp and trust for patients. As a result, the average number of billing disputes cuts down dramatically.  

Real-time verification speeds up the confirmation process for patients. Verification software can inform them about available service coverage. This tool provides a clear picture of benefit limits, possible expenses, and copays. Cost estimation helps to plan payments and avoid extra medical bills.  

Improved protection and safety 

Data compromises are a problem for the medical insurance system. The number of compromised cases has increased over the past several years.  

This tendency demonstrates that the possibility of falsified medical records is getting higher. These lead to both financial issues and the risk of improper medical treatment. Companies spend billions of dollars to cover the consequences of such cases. The statistic demonstrates the importance of improving the system’s safety. 

Accurate patient identification helps make sure that the rightful patient receives all the treatment required. Some insurance companies choose biometric identification. They record data for face recognition or fingerprints for further personal verification. 

Insurance verification software must remain compliant with HIPAA, providing a high level of patient privacy and safety by allowing only authorized persons to use patient data for intended purposes.  

Customization, analysis, and reporting 

You can customize the workflow according to specific needs and requirements. Our specialist can help you select the best-fitting solutions for specific needs and purposes.  

Integrated tools for analysis and reporting further help track performance data. They analyze verifications and trends, helping to detect weak points in the system and improve them further.   

Patient satisfaction 

Efficient insurance verification software enhances the patient’s experience with a range of pain-solving solutions and advancements. 

1. Automated insurance processes speed up check-ins and confirmations. Speeding up saves time and costs required for insurance verification.  

2. The billing is more accurate and up to date. The software reduces the possibility of errors and unexpected extra bills. It also reacts to claims faster. 

3. Simple access to patients’ information guarantees clear communication. Transparency helps to form a better imagination about the insurance system. It reduces anxiety about medical services and expenses. Real-time verification helps to confirm insurance coverage levels faster as well.  

4. The software informs staff about any insurance issues. It helps to fix the problem before it can affect the patient in any way.  

These factors affect patient satisfaction and make the whole insurance process smoother.  

Key features of medical insurance verification software

Our experience shows that the most valuable features a good insurance verification system can boast include: 

• Real-time verification. The software connects with medical services to check on insurance coverage and limits. It gathers the data from the moment of registration. Provided information helps to check data faster during the insurance procedure. 
• Pre-authorization. If the procedure requires pre-authorization, the software can provide an automatic application. It checks for necessary approvals and reduces the number of last-minute cancellations. 
• Batch workflows. This feature enables the processing of several patients simultaneously. It takes a lot of time to process patient’s requests one by one. The right software can fix this problem and make the procedure smoother. 
• Data scrubbing. The verification software can check the data, detect errors, and prevent incorrect processing. Error scrubbing minimizes the claim denials caused by invalid information. 
• Resubmission. This feature ensures up-to-date correction and resubmission of patient information to insurance companies. It helps to keep records clear and updated in time. 
  
  Other must-integrate features include notifications, dashboards, reports, and payment calculations. You can choose the combination of features suitable specifically for your requirements. We review each case and offer the most efficient solutions.  

Insurance eligibility API: How to create a custom medical insurance verification software?

Starting from the early 90s, API technology transformed the digital infrastructure of the fintech industry. Before you are required to step into a physical bank to access your money. Now, you have the ability to access your financial assets in real time through ATMs or apps via the digital infrastructure of API.

Eligibility products take a page from this history in the financial industry. These products establish real-time access to any patient’s benefits coverage information like a patient’s coverage status, deductible limits, spending amounts, or payment details. In the background, they handle the complex infrastructure of trading partner connections throughout the healthcare industry. So, you can get access to what you really care about. With proper eligibility products, you can give a provider accurate insurance information at the point of care, which can provide faster payments and more revenue.

As you can see, eligibility products provide many benefits for medical practices and hospitals. However, you can get the most out of eligibility solutions if you build a custom product from scratch. Here is a comprehensive guideline that will help you understand how we build custom healthcare solutions.

Learn about how to build insurance agency management software.

A step-by-step guide to custom health insurance verification platform development

Here are the key steps to build bespoke solutions for medical insurance verification.

Step 1 – Gather all the initial requirements of the stakeholders.

Make sure that you collected the wants and needs of every single user of the future program. Discuss these requirements with a reliable software development company. Here are several options for you:

• In-house IT staff with suitable expertise and skills (rarely happens)
• On-shore IT company (costs may be high)
• Outsourcing provider (lower costs + needed skills)
• Technology partner (reasonable costs + needed skills set + business analysis)

Depending on your budget and the project’s complexity, the total cost of the product may vary greatly. However, if you have any doubts about the number of features you need, you should consult a professional software development team and then decide on the available options.

Step 2 – Get the results of the business analysis.

If you contact a reliable vendor with a strong background in healthcare tech solutions, they will definitely offer you a comprehensive business analysis. It means they will thoroughly examine all the challenges the medical staff faces every day when verifying medical or dental insurance. This analysis provides a deeper understanding of all the operational processes within your organization in particular and within the healthcare industry in general.

Together with challenges reports, you will get a complete list of possible solutions that you can discuss in advance.

Based on the requirements list and business analysis, your development team or partner will provide you with SRS documentation that contains detailed specifications and design requirements. Once the prototype and specs are approved, developers start creating an MVP.

Step 3 – Developers build a minimum viable product.

With MVP, you will be able to evaluate whether it is easy to use the software, what features you need more, and get feedback from real users. Based on feedback and reviews, developers will be able to understand if they met the initial requirements and check if the software needs to be further improved and optimized.

While developing an MVP, test engineers test the product for performance, functionality, UI, and other stuff. They check it for bugs and errors to timely eliminate all the issues.

Step 4 – Our technical team provides support and maintenance services.

Once the product is done, our customers are offered maintenance services in case they need further enhancements or new functionalities. The product is also supported by a professional customer support team 24/7.

As you can see, the procedure is quite easy and clear. Contact, discuss, test, and launch.

Why custom medical insurance verification software is better than out-of-the-box products?

To help you choose between a custom solution or commercial software, we compared these products.

Out-of-the-box solutions work best for the following purposes:

• Your end-users are internal
• Your business processes are clear
• You don’t need scalability
• All your systems are up-to-date
• You need to implement new technology asap
• You have no in-house staff

Custom solutions are best suited for the following purposes:

• You have both internal and external users
• Your business processes are constantly evolving
• You need scalability
• Some of your systems are legacy
• You have time to wait for a fully customizable solution
• You have some tech specialists in the office

In terms of medical insurance, scalability is the major difference between a custom solution and a commercial one. The number of external users in the healthcare insurance industry is constantly growing, so you will definitely need to scale up your verification platform to ensure the right performance of your product.

The next key benefit of a custom solution is unlimited consulting and regular communication. When cooperating with a professional software development team, you can ask questions about unclear topics to developers and get detailed and clear answers from experts. Any change requests or other issues are solved instantly without any delays.

If you need an expert opinion on medical software development, feel free to consult with our developers. Our company comprises dedicated teams with vast experience in a particular industry or business domain, including insurance, healthcare, e-commerce, finance, etc. Thus, we are ready to answer your questions and give expert recommendations for your project.

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