Blog Post

Eligibility Verification and Your Front Office

Eligibility verification may seem like a simple task, but without performing this step & collecting pertinent information, your claim is dead in the water.

Lauren Milligan
5 min read
July 22, 2015
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The success or failure of each patient claim begins and ends in the front office. Why? Patient insurance eligibility verification is the first—and perhaps most critical—step in the billing process. That means your front office has to be on the ball to obtain and accurately record all eligibility information. Your staff is responsible for determining each patient’s insurance eligibility, including:

  • coinsurance or copay,
  • deductible,
  • benefits cap,
  • where to send the claim,
  • whether the payer requires specialized forms or additional documentation, and
  • whether the payer requires authorization. Some payers will retroactively authorize services, but for those that don’t, you need authorization before you begin providing services.

Let’s Talk Verification

Insurance Re-Verification

Your front office also should re-verify patient insurance when appropriate. For example, if your patient gets a new job, he or she will have new benefits—and that means you've got to complete a new eligibility check. But benefit details—like deductibles, copays, coinsurances, and type of coverage—can change at the beginning of the year and/or month. So, if you haven’t seen the patient for a while, or if you recently flipped a page on the wall calendar, then it’s time to re-verify insurance.

Verification Period Policy

Consider implementing a 72-hour verification period policy for your front office. By checking benefits within a short window of time before the patient’s appointment, you’ll help ensure patients are clued in to their financial obligation so collecting payment is easier. Plus, it saves you from no-shows and day-of cancellations due to high deductibles.

Auto Insurance Verification

If you work with auto accident patients, don’t forget to verify eligibility with their auto insurance companies, too. You can even include a separate section for it on your patient intake forms, like Physical Therapy and Sports Medicine Center did here. Just as you would with a regular health insurance company, verify that the patient is covered and confirm that the patient is approved for physical therapy visits. You should obtain proof of authorization—and provide the auto insurance company with any necessary authorization forms—before providing any kind of service.

Let’s Talk Qualifications

Now that we’ve nailed down the process must-dos, let’s make sure your front office staff is ready and willing to take on these responsibilities. There are several characteristics to look for when filling front office positions:

  • A love—or at least an understanding—of billing. This way, your true billers can handle the back-office duties they’re supposed to manage, instead of wasting time making up for front office billing mistakes.
  • Confidence in collections. With copays and cash-pay on the rise, you’ll want to hire someone who’s not afraid to talk to your patients about their copays, coinsurances, or overdue balances—and, you know, actually collect the money you earned. Otherwise, you’re leaving a lot of money on the table—all day, erry day.
  • Detail-oriented. Determining eligibility requires your front office staff to do more than just call the patient’s insurance company and ask if the patient has a plan. They must gather a ton of info—and then be able to cross all the t’s and dot all the i’s. Sloppy data entry equals denied claims and decreased revenue.
  • Tech-savvy—at least when it comes to your practice management and documentation software. This way, you’ll spend less time and money training that person on a crucial part of your billing processes. Less training means a smoother transition and an earlier return on your investment.

Eligibility verification may seem like a run-of-the-mill task, but without performing this step and collecting all the pertinent information, your claim is dead in the water. With a capable and confident front office staff, you can greatly reduce your clinic’s number of underpaid claims, denied claims, and delinquent accounts—and dramatically improve your bottom line.


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