Eligibility Verification

A complete Medicare check covers five things:

• Part A and B entitlement and effective dates
• Medicare Advantage enrollment, including which plan and its effective date
• Hospice election periods, since home health claims overlapping a hospice election for related care will deny
• Open home health episodes at other agencies, which require transfer handling rather than a fresh admission
• Medicare Secondary Payer situations where another insurer pays first

For Medicare Advantage patients, verification extends to plan benefits and authorization requirements, because MA coverage without authorization is usually not payable.

Every item on the checklist maps to a denial. Admit a patient enrolled in a Medicare Advantage plan and bill traditional Medicare, and the claim denies while authorization deadlines pass. Miss a hospice election and related home health claims deny. Miss an open episode at another agency and the Notice of Admission and payment sequence tangle, sometimes triggering partial episode payment adjustments for the other agency and payment problems for yours. These denials are especially painful because the care was delivered in good faith and often cannot be billed to anyone. Verification is cheap; the alternative is free care.

Eligibility is a moving target, so one check at referral is not enough. Verify at referral to triage quickly, again immediately before the start of care, and then monthly while the patient remains on service, since beneficiaries can switch between traditional Medicare and MA plans with month-to-month effective dates. January deserves special attention: annual enrollment period changes take effect January 1, and every patient on census should be rechecked. Recertification is another natural checkpoint. Agencies that automate recurring checks catch mid-episode plan switches and hospice elections while there is still time to redirect billing and secure authorization.

The failure patterns repeat across agencies: verifying once at referral and never again, relying on the insurance card the patient presents rather than a live transaction, skipping the hospice and open-episode checks because entitlement looked fine, and treating MA verification as done once enrollment is confirmed without checking authorization requirements. Another quiet one: intake teams under census pressure admitting before verification completes, betting the paperwork will work out. What good looks like is boring and reliable: a standard checklist run through a real-time source at defined points, with clear rules for what blocks admission versus what proceeds with flags.