The 6 Best Ways for Providers to Verify Medical Coverage

Every day, approximately 200 million claims are denied, meaning about one in seven claims is not approved. Of these denials, around 27% occur due to issues with patient registration and eligibility.

Handling these denials can be costly, with each rejected claim averaging $25 to manage. This situation can create significant cash flow challenges for practices’ revenue cycle management (RCM).

Eligibility coverage problems not only increase billing costs but also delay revenue collection, disrupting the entire revenue cycle.

Utilizing a reliable insurance verification method can help prevent denials, simplify medical billing, and enhance your bottom line.

This guide will explore various methods for verifying a patient’s Medicare insurance eligibility.

What is Medicare Coverage?

Medicare is a federal health insurance program established in 1965 that provides coverage for individuals aged 65 and older, regardless of their work history, income, or health status. The program is overseen by the Centers for Medicare and Medicaid Services (CMS), part of the U.S. Department of Health and Human Services, and operates under Congressional guidance.

Medicare is not designed to cover all medical expenses; its purpose is to assist with a portion of costs. Beneficiaries remain responsible for certain out-of-pocket expenses, such as deductibles, copayments, and any services that Medicare does not cover.

Medicare consists of four parts:

• Part A (Hospital Insurance): Covers costs related to inpatient hospital care, skilled nursing facility care (after a hospital stay), certain home health care, and hospice care.
• Part B (Medical Insurance): Addresses expenses related to doctor visits, various medical services, and supplies not covered by Part A.
• Part C (Medicare Advantage): Previously known as Medicare + Choice, this plan allows individuals with Part A and Part B to receive all their healthcare services through a single provider organization.
• Part D (Prescription Drug Coverage): Helps cover the costs of prescription medications prescribed for treatment.

Why Verify Medicare Coverage?

Verifying Medicare coverage is crucial for providers as it streamlines the revenue cycle and enhances the collection process. According to CompuGroup Medical, manual verification can cost the equivalent of two patient visits per day, totaling around $6,000 annually. Transitioning to electronic verification can save time, money, and effort.

Here’s why it’s vital to verify Medicare eligibility in advance:

• Checking eligibility upfront increases the likelihood of claims being approved on the first attempt and reduces accounts receivable (A/R) days, leading to faster payments.
• Verifying coverage before services are rendered allows you to understand your patients’ co-pays, co-insurance, deductibles, and out-of-pocket expenses, facilitating more efficient payment collection.
• Early eligibility verification enables you to inform patients about their insurance plan details, co-pays, and deductibles ahead of time, resulting in higher patient satisfaction and fewer billing disputes.
• Confirming eligibility prior to providing services helps maintain a steady cash flow by preventing payment delays.

How Do You Check Your Patient’s Medicare Eligibility Status?

Here are the top six methods for providers to verify Medicare coverage:

Method #1: Invicta MD Medicare Coverage Verification

1. Visit Invicta MD.
2. Complete the form with your name, email, phone number, and monthly billing, then click “SUBMIT NOW.”
3. A representative from Invicta MD will contact you promptly to assist in confirming your patient’s Medicare coverage.
4. Alternatively, you can call Invicta MD at 800-640-6409 for assistance with verifying Medicare coverage.

Method #2: Using the Secure Provider Online Tool (SPOT)
The Secure Provider Online Tool (SPOT) enables you to check claims status and patient eligibility online, as well as look up a Medicare Beneficiary Identifier (MBI).

With SPOT, you can access eligibility information 24/7, including details on Part A and Part B coverage, preventive services, deductibles, therapy caps, inpatient and hospice care, home health, Medicare secondary payer (MSP), plan coverage, and claim status for up to a year.

To check patient eligibility with SPOT:

1. Select “Eligibility” from the top drop-down menu.
2. A pop-up will appear requesting the following information:
   • Last Name of Beneficiary
   • Medicare Beneficiary ID
   • First Name of Beneficiary
   • Beneficiary’s Date of Birth
   • Date(s) of Service

Note: You can narrow your search to the service date or choose a range of up to four months in the future and 24 months in the past.

3. Click “Search” to verify the eligibility status. The results will provide full details on the beneficiary’s eligibility, including statuses for Part A and Part B, along with effective and termination dates.

Method #3: Verifying Medicare Part A & Part B Eligibility via IVR
The Interactive Voice Response (IVR) system allows you to verify Medicare eligibility over the phone, providing details about the patient’s primary insurance, primary care doctor, and checking pre-authorization or claim statuses.

For Medicare Part A, call:

• 1-888-664-4112 (Toll-free)
• 1-877-660-1759 (For those with hearing impairments)

For Medicare Part B, call:

• 1-866-454-9007 (Toll-free)
• 1-877-660-1759 (For those with hearing impairments)

IVR service is available during these hours (excluding holidays):

• Monday to Friday: 7 a.m. to 7 p.m. ET
• Saturday: 6 a.m. to 3 p.m. ET

For more complex inquiries regarding insurance plans and benefits, Customer Service Representatives (CSR) are available during:

• Monday to Friday: 8 a.m. to 4 p.m. ET (For Florida providers: CT)
• 8 a.m. to 4 p.m. ET (For providers in the U.S. Virgin Islands)

Method #4: Verifying Eligibility via MAC Online Provider Portal
Medicare Administrative Contractors (MACs) manage claims and eligibility verification for Medicare and provide online portals for providers to handle these tasks.

If you are not yet registered with your MAC:

• Contact your MAC or find their portal online to register.
• Once registered, you can use the portal to verify a Medicare beneficiary’s eligibility by entering:
  • The beneficiary’s Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
  • The beneficiary’s first and last name
  • The beneficiary’s date of birth

The portal is available for self-service anytime.

Method #5: Verifying Eligibility by Phone with MAC
MACs also offer phone-based verification. You can find the MAC phone number on their website based on your state.

To verify eligibility, you will need to authenticate through the phone system using:

• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• Tax Identification Number (TIN)

Once authenticated, provide:

• The beneficiary’s HICN or MBI
• The beneficiary’s first and last name
• The beneficiary’s date of birth

This service is available 24/7.

Method #6: Using the HIPAA Eligibility Transaction System (HETS)
The HIPAA Eligibility Transaction System (HETS) allows for eligibility verification through a secure, HIPAA-compliant transaction. You will need to submit a HETS 270 request with:

• MBI
• First and last name
• Date of birth (MM/DD/YYYY)

If the patient is eligible, you will receive a 271 response containing details such as Part A and Part B entitlements, Part D coverage, remaining hospital lifetime reserve days, and skilled nursing facility days.

Note: To utilize HETS, your medical billing software must be integrated with the system. This setup is particularly beneficial for larger healthcare facilities that want to manage everything in-house quickly and securely.

When managing Medicare patients, providers must check their coverage beforehand. Always verify the patient’s eligibility before scheduling appointments to understand what services Medicare will cover and the patient’s out-of-pocket costs. This early verification helps maintain a smooth revenue cycle and prevents any unexpected bills later on.