Patient Registration and Eligibility Verification
Getting the foundation right
Registration is where identity, coverage, and financial responsibility are established. Core concepts: patient identity verification (name, date of birth, member ID), insurance eligibility and benefit verification (active coverage on date of service, plan type, network status), coordination of benefits (COB) when a patient has multiple payers, prior authorization requirements, and patient financial responsibility estimates (deductible remaining, coinsurance, copay).
Understand the payer hierarchy: primary, secondary, tertiary. The primary payer adjudicates first; the secondary considers the primary's EOB. COB rules (e.g., birthday rule for dependent children, Medicare Secondary Payer rules) determine order. Also know in-network vs. out-of-network implications and point-of-service collection as a front-end function.
Traps in questions
- Treating "eligibility verified" as "benefits verified." Eligibility confirms active coverage; benefits confirm what is covered and the patient's cost share.
- Forgetting that prior authorization must match the service, date, and provider; a mismatched auth causes denial even if one exists.
- Assuming the patient's stated insurance card is current - always verify against the payer.
- Missing COB, leading to a primary payer denial or improper billing.
Rule of thumb
Verify eligibility and benefits before the date of service, document the source and timestamp, and collect the estimated patient responsibility at or before service when policy allows.
Worked example
A patient presents a card showing active coverage, but the payer portal shows a terminated plan with a new secondary. Correct action: update COB, bill the correct primary, and re-estimate patient cost share - do not simply bill the card as shown.