How to Verify Medicare Eligibility Status Quickly and Easily

For physician practices, hospitals and all healthcare organizations, streamlining your revenue cycle management is critical. One of the best ways to recoup payments faster is by realizing the value of doing an upfront Medicare eligibility check for every patient. With changes in the Affordable Care Act, patient responsibility is often in play and healthcare organizations who can communicate effectively with patients about how to pay for their medical treatment will be more successful at collecting full payments.

Verifying Medicare eligibility before and during patient care is one of the most direct ways to reduce claim denials and speed up reimbursement. In this guide, we’ll walk through:

• Why a Medicare eligibility check matters for your revenue cycle
• How often to verify Medicare eligibility throughout a patient’s course of treatment
• What patient information you need to run a Medicare coverage verification
• What eligibility data you can use to communicate costs to patients upfront
• How Inovalon’s tools make Medicare insurance verification faster and more accurate

The importance of doing a Medicare eligibility check

Medical benefits are always changing so it’s important to check the Medicare status of your patients often whether it’s for prescription drugs or a specific procedure. This can cause a strain on some physician practices, care facilities, hospitals and other healthcare organizations. Save staff time and resources and quickly determine Medicare status with Eligibility Verification Medicare. With 24/7 access to Medicare’s HETS database, your staff will be able to gather real-time, detailed eligibility status and medical benefit information, allowing you to:

• • Receive payments faster by verifying Medicare eligibility at the beginning of patient care
  • Reduce staff workload
  • Quickly identify Medicare replacement plans and secondary payers
  • Reduce denied claims with upfront identification of Medicare supplement or Medicare Advantage plans

How often should you check Medicare eligibility?

It’s important to check your patient’s Medicare eligibility throughout their course of treatment. Working with an information technology company can help reduce the time spent completing these frequent Medicare status checks. At the very minimum, you should check Medicare status:

• • The first time the patient reaches out to you for medical service
  • Before any submission of a home health request for anticipated payment (RAP)
  • Before any submission of a hospice notice of election (NOE)
  • Before every claim submission

What information do you need to check Medicare status?

To check Medicare eligibility, you must have the following patient information:

• • First and last name
  • Medicare Beneficiary Identification number (MBI)
  • Date of birth (month, day, 4-digit year)
  • Gender

What can you communicate to patients with a Medicare eligibility check?

Communicating often and effectively with patients is key to receiving complete payment for medical services in a timely manner. Being able to check Medicare status quickly and often will allow you to know and communicate to patients:

• • The deductible amount they have remaining for the year
  • Information about their primary insurance if Medicare is the secondary payer
  • Any patient-enrolled Managed Care Organization (MCO) or Health Maintenance Organization (HMO)
  • That status checking is 100% HIPAA compliant

Complete fast, accurate Medicare eligibility checks with Inovalon

No matter the size your practice or healthcare organization, Inovalon can help simplify complex revenue cycle management processes with the latest data-driven applications. You can count on us to optimize reimbursements and the quality of care you offer.

Request a demo today. We look forward to helping your organization grow!

Frequently asked questions on Medicare eligibility verification

How do I verify Medicare eligibility for a patient?
To verify Medicare eligibility, you need the patient’s first and last name, Medicare Beneficiary Identification (MBI) number, date of birth, and gender. With that information, you can run a Medicare eligibility check through a system like Inovalon’s Eligibility Verification tool, which connects directly to Medicare’s HETS database for real-time results. The process is 100% HIPAA compliant.

How often should I check Medicare eligibility?
Check Medicare status at the patient’s first contact, before submitting any home health request for anticipated payment (RAP), before submitting a hospice notice of election (NOE), and before every claim submission. For complex or ongoing cases, more frequent Medicare coverage verification reduces the risk of claim denials.

What does a Medicare eligibility check actually tell you?
A Medicare eligibility check returns detailed benefit information, including:

• The patient’s remaining deductible for the year
• Whether Medicare is primary or secondary
• Any active Managed Care Organization (MCO) or HMO enrollment
• If the patient has a Medicare Advantage or Medicare supplement plan

That data lets your staff flag billing issues before they become denials.

Why does Medicare insurance verification reduce denied claims?
Most claim denials tied to eligibility happen because coverage details weren’t confirmed upfront; a patient may have switched to a Medicare Advantage plan, have a secondary payer, or have a lapsed benefit. Running a Medicare coverage verification before each claim submission catches those discrepancies early, so your billing team isn’t chasing corrections after the fact.

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