How to Achieve a Strong Eligibility Verification Process

While a strong revenue cycle is the financial heart of every successful organization, healthcare providers often struggle to keep revenue flowing due to denials and other workflow disruptions. In fact, one Inovalon survey of more than 400 healthcare leaders found that claims denials were the top challenge to maintaining a healthy revenue cycle across all care settings. Furthermore, 87% of leaders and managers attributed claims denials to at least one workflow at the front end of the revenue cycle ― insurance eligibility and benefits verification was cited as the top contributor to denials, with 67% of respondents pinpointing eligibility verification as a leading cause of denials and revenue cycle disruption.¹

A healthy revenue cycle begins with a solid eligibility verification process, which can reduce denials, allow for timely payments, save staff time, and provide a better experience for patients and residents. So how can you recognize whether your organization is set up for success from the start of the revenue cycle? Here are some considerations to assess your eligibility verification process.

Insurance eligibility verification should be timely

Verifying insurance eligibility must be part of the patient intake process. Prior to the patient encounter, staff should review the patient's records to ensure that all of their data - patient demographics and insurance information - has been accurately recorded. From there, an eligibility inquiry is submitted to the health plan to verify current coverage, determine copays or deductibles, and to guarantee that any required authorization has been obtained.

Timely verification protects providers from unexpected hiccups in the revenue process that may occur because of recent changes in insurance coverage, missing or incorrect patient information, or missing authorizations. It also allows for a better patient experience because it accelerates access to care.

All sources of insurance coverage should be identified

More than 13% - or 43 million - Americans are covered by more than one health insurance policy.[2] That's why verifying insurance eligibility should involve checking across multiple sources of coverage. This can help providers identify additional payers, while helping to alleviate the cost burden for patients and improving satisfaction.

Of course, verifying insurance across multiple payers can be time consuming. It also relies on patients and residents self-reporting all of their health insurance policies. As a result, many providers take advantage of software that can automate insurance eligibility verification. This can save time in checking multiple sources of insurance coverage and help find sources of coverage that patients may not have reported or may not realize can help cover the cost of their care.

Identifying all sources of coverage becomes especially important for older patients or residents with Medicare coverage. That's because more than 52% of Americans age 65 and older are covered by more than one health insurance plan, largely due to supplemental Medicare plans, according to the U.S. Census. In all, more than 25 million Americans are covered by both Medicare and private insurers.² The right solution also can relieve the challenges of verifying Medicare coverage, which is often tedious and complicated. Rather than working in the "green screen" Direct Data Entry (DDE) system, using more modern, easy-to-use eligibility software can help confirm Medicare coverage, incluing finding the Medicare Beneficiary Identifier - without the usual challenges associated with verifying Medicare eligibility.

Insurance eligibility verification should be efficient

Verifying insurance eligibility can be a time-consuming process for billing staff. Manual verification requires contacting each insurer - either by phone or through the insurer's web portal - to confirm that coverage is current, that the visit or procedure is covered, and that any needed referrals or authorizations have been submitted and accepted. This becomes even more time consuming if patients or residents have missing information or multiple sources of coverage because each payer must be contacted individually.

Patient data and coverage data - where unavailable or inaccurate - prevents full and timely reimbursement. Delays in verification can impact access to care, as services may need to be delayed or canceled. One way to ensure efficiency in eligibility verification is through automation that can check coverage for multiple patients or residents at once. This can save staff time, keep the revenue cycle moving quickly and smoothly, and accelerate access to care.

Why it's important to establish a strong eligibility verification process

Because accurate insurance verification is the backbone of the revenue cycle, providers need to be able to understand the components of a strong verification process to drive patient or resident satisfaction and improve access to care. Efficient and timely insurance eligibility verification can improve cash flow, reduce denials, allow providers to collect payments faster, and provide a better patient and resident experience by identifying financial responsibility accurately and up front.

Inovalon's eligibility verification solutions can help improve accuracy, save staff time, accelerate care access, and improve RCM performance - all by better identifying patients' active coverage. Explore patient access software.

1. Inovalon survey, April 2024

2 "About 42 Million People in the U.S. Had Multiple Health Plans in 2021," Mykyta, Laryssa; Keisler-Starkey, Katherine; Lindstrom, Rachel; Bunch, Lisa; United States Census Bureau, July 19, 2023, https://www.census.gov/library/stories/2023/07/multiple-health-coverage-plans-in-2021.html#:~:text=About%2043%20Million%20People%20in%20the%20U.S.%20Had%20Multiple%20Health%20Plans%20in%202021

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