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Tips for Streamlining Workflow: Eligibility

It can be very frustrating to provide comprehensive care to a patient, such as diagnostic tests, a physician visit, or a procedure, only to find out that the patient’s insurance does not cover the care provided. This cannot only have a financial impact on a practice in terms of a denied claim, but it can also reduce workflow efficiency when staff is spending time reacting to a patient’s lack of insurance coverage rather than proactively anticipating it.

Having a well-defined process in place for verifying eligibility can help make sure your practice identifies coverage issues upfront and prevent denials down the line. The first and most critical step in realizing a well-defined process is to shift the verification effort from reactive to proactive. In other words, checking eligibility before a patient arrives at the practice for an appointment—not after. This ensures potential insurance coverage issues are identified upfront. Your practice may want to consider starting the eligibility verification effort at scheduling, which allows you to work through coverage issues well before any care is is provided.

Eligibility verification can be manual or automatic. The advantages of automation include significant time savings and enhanced accuracy. An electronic eligibility verification tool can run batch verifications in advance of patient visits, allowing you to check coverage for literally hundreds of patients with the touch of a button. This type of system flags any patients who could not be verified, allowing front desk staff to query those patients when they arrive for their appointment. An automated verification tool can even help with walk-ins in that it verifies insurance in real time when the patient checks in.

Another critical element in a strong eligibility verification process is communication. The more your scheduling staff, front desk staff, nurses and physicians know about what a patient’s insurance covers, the more likely your practice will not provide services for which it won’t get paid. Automated eligibility verification tools that link with practice management systems can support effective practicewide communication by ensuring everyone involved in a patient’s care is aware of his or her’s eligibility constraints.

A final component of proactive eligibility is a responsive denial management process. While denials should be significantly reduced once a reliable verification process is in place, it is still beneficial to stay on top of rejections and denials and identify any negative patterns that can be addressed to prevent future issues.

What things has your practice found helpful when working through eligibility? How has automating the process helped improve efficiencies?