Insurance eligibility and verification is the process of confirming 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 a verification process. During this stage, 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, 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.

medical insurance verification solutions

What Is Medical Insurance Verification?

Hospitals and doctors offices or any 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 is just asking 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 patient’s benefits. In the background of these manual processes, there exists an entire industry of third-party partners which 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 technology 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 is 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.
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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 managing authorizations and informing front-office when a patient is out of authorization.
  • Data scrubbing feature allows verification specialists to check the patient’s information for completeness, make changes in the information, etc.
  • Calculating insurance payments feature allows managing deductibles, co-pays, benefits coverage, and co-insurance.
  • The reporting feature allows checking certain information for a certain period of time in a single screen.

Dental Insurance Verification Software

Dental insurance verification works in 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. This makes the dental practice look disorganized in the eyes of the patients.

Modern dental insurance verification software takes care of the complete insurance verification process while dental practice can focus on delivering the best patient experience. The software verifies eligibility prior to patient appointments. It provides regular updates in a change of plans. Customers are able to discuss their benefits with the staff as soon as they come into their appointment.

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

Why Medical Insurance Verification Software Is Important for Medical Practices?

As a part of 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 giving 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 with patient data. These capabilities automate the entire process of verification, reduces manual and redundant tasks, saves time, and cuts administrative costs.

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

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 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 ATM 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, the 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.

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A Step-by-Step Guide to Custom Health Insurance Verification Platforms Development

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 actually high);
  • outsourcing provider (lower costs + needed skills);
  • technology partner (reasonable costs + needed skills set + business analysis).

Depending on your budget and the project 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 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 an SRS documentation which 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.

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Why Custom Medical Insurance Verification Software Is Better That 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 office.

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

The next key benefit you get with a custom solution is unlimited consulting and regular communication. When cooperating with a professional software development team, you will be able to ask questions about unclear stuff 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 consists of the dedicated teams each of which has a 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 as per your project.