The Importance of Eligibility Verification in Revenue Cycle Management

The revenue cycle is an essential aspect of any healthcare organization. It includes the management of claims, payments and revenue. One of the most important steps of revenue cycle management (RCM) is eligibility verification – the process of checking the patient’s insurance before providing care.

In this article we explore how eligibility verification in RCM can be useful for healthcare providers.

Reducing Claim Denials

Eligibility checking aims to cut down on claim denials. It allows staff to spot any coverage issues early, gather necessary documents, confirm service agreements, check deductibles, and take other steps to ensure claims meet payer requirements. This proactive approach prevents many common causes of denials:

• Lack of active coverage
• Exhausted benefits
• Prior authorization not obtained
• Non-covered services
• Failure to spot changes in coverage

Fewer denied claims result in higher first-pass acceptance rates, quicker payments and little time spent on appeals. It is common to observe that organizations benefit from improved productivity, decreased accounts receivable, and increased revenues.

Staying Up-To-Date on Patient Coverage Changes

Health insurance coverage is not always static. Here is the list of the most frequent changes:

• Change of the coverage plan
• Switching insurance companies
• Changes in dependent status

Without thorough eligibility checking, these changes can go unnoticed. Claims get filed under outdated coverage information and are inevitably denied.

Automating the verification process allows staff to regularly check for any updates. Alerts highlight changes, ensuring claims reflect active benefits. This prevents eligibility errors.

Enhancing Patient Financial Experience

Eligibility verification improves financial outcomes for patients as well as providers. With staff aware of coverage specifics ahead of time, patients gain more predictable out-of-pocket costs. Organizations can collect prepayments when required and set accurate payment expectation.

Automation also allows staff to outline various treatment options and associated patient costs. This empowers patients to select care plans that align with their financial means and insurance benefits. More financial clarity and control lead to higher patient satisfaction.

Key Features  of Eligibility Verification Solutions

Now that we have covered the critical reasons for eligibility verification in RCM let’s explore key features to look for when evaluating solutions:

Real-Time Eligibility Checks

Outdated patient coverage data leads to avoidable claim problems. Automated verification allows to check patient’s data in real time thanks to connection with the latest payer databases. 

Batch Verification

Manually verifying one patient at a time can take a lot of effort.e. Leading solutions allow users to automate routine verification for a group of patients (as many as you need) in a single file, which saves a lot of time for the staff.

Track Historic Data

Users can research previous coverage information directly within the system when needed for administrative or billing purposes.

Ongoing Coverage Monitoring and Alerts

Leading verification solutions do more than just one-off checks; they continuously monitor coverage changes. Staff receive alerts about any status changes, including revisions or cancellations of benefits. This ensures that everyone stays up-to-date, avoiding potential eligibility errors by using only the latest data.

Seamless Workflow Integration

The best eligibility tools seamlessly embed into existing workflows for the admissions staff, billing staff, and others. User-friendly interface allows fast access directly within practice management or EHR systems.

Mobile Extension

Check whether the software provider has a dedicated mobile app. This can be an additional benefit as it allows for instant verification from anywhere in the facility, quickly confirming coverage.

Verifying insurance on the go is especially useful for admissions staff, as it lets them move freely around the facility and handle patient registrations efficiently without returning to a central workstation or facing delays.

 Why Should I Consider an Automation Tool

As emphasized throughout this piece, eligibility verification is essential for solid RCM. Using automated verification technology provides:

• Fewer claim denials and rework
• Maximized reimbursements
• Better patient financial experiences
• Enhanced administrative and billing staff productivity

Compared to most EHR/PM systems that include basic built-in verification, standalone solutions are more reliable.  Investing in advanced verification capabilities leads to more payments, fewer write-offs, and improved long-term revenues.

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