The Importance of Patient Eligibility Verification in Revenue Cycle Management

“Prevention is better than cure”, a 17th Century proverb that has it’s roots in the medical profession is now finding a stronger calling in the same profession albeit for a different reason.

Recent reports shows that “claim denials” are on an upward trend putting your cash flows into jeopardy. Quite different from rejection that happens due to lack of right data or codes or as simple as a patient’s insurance policy number, denials are generally received and processed by the insurance company but stamped as “non-payable”. Denials add to the ever-expanding gaping hole in your revenue calculations.

While the losses can be colossal, they are potentially “preventable”. A detailed root cause analysis of such claim denials can help you find the earliest stage a denial could have been stopped before it happened. And, that’s the first win against this malady.

Let’s look at one of the key contributors to this damage and how you can prevent it from happening in the first place.

One of the earliest stages of prevention is through a patient’s eligibility check. An eligibility check requires verification of patient’s insurance with their demographic essentials, coverage status, authorization, and similar details that prove the patient’s eligibility for the needed treatment. A simple error of checking eligibility during an appointment rather than during an actual visit can lead to a probability of error.

Patient Eligibility Verification in Revenue Cycle Management

Patient Eligibility Verification in Revenue Cycle Management

Key ways to strengthen the patient eligibility check process include

Audit and Train: Knowing what processes are currently employed at present to verify a patient’s eligibility is the first step that you need to do. Once you know these processes, a careful review of each step needs to be done. Common mistakes are known to occur due to inefficient processes. Regular training programs to staff on eligibility verification can keep maintaining checks on the practice.

Leverage Technology: It’s probable that from the audit you would gather some steps which are manual and mundane. A manual process carries a huge probability of getting things wrong. A few of the areas where technology can play a key role are:

  • Adding cloud-based software that provides the latest information on patient coverage on a real-time basis so that you can make a well-informed decision.
  • Claim Status automation software that fetches the real time status for the submitted claim. This notifies you about any denial or delay on payment from the payer. This practice assists you overcome the future denials. A professional Revenue Cycle management outsourcing company can help ease out the overall process.
  • Measure, Monitor and Analyze: Measure and monitor is a continuous activity that serves as a scorecard of your success in minimizing denials. Along with measuring your denial rate, an effective mechanism to monitor denials complemented with analytics can be of immense value. Predictive analytics can give you insights into which particular claim carries a high risk of denial based on a similar type of denial from the same payer in the past.

A denied claim cannot be resubmitted but can only be appealed and that’s expensive in time, money, and other resources. For a while even if we assume that a denied claim can be successfully appealed and recovered, you would still be staring at the costs gone in for the recovery. Simple steps above that help you overcome the loss.


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