When it comes to eligibility and benefits, there are time, cost and revenue loss implications that pose significant risks to providers. On top of the annual changing of healthcare benefits for American households, as of January 1, 2024, 16 million Medicaid members have lost coverage due to Medicaid redetermination.1

This leaves physicians caring for patients in a situation where patients may not have insurance coverage or may present with expired coverage. Patients rely on the practice to provide information about their insurance benefits. If health records data is inaccurate, this causes an increased chance of a denied claim, and in turn, causes more financial burden to patients.

Practices must find ways to mitigate eligibility and benefit related denials. Doing so will reduce administrative stress on staff members and increase patient satisfaction levels. This is where key technology can make a positive impact. Implementing automation and revenue cycle management (RCM) technology can empower your staff, leading to better patient care and stronger overall business growth.

Eligibility struggles

According to the 2023 CAQH Index Report, annual amount providers spent in 2023 on electronic eligibility transactions for medical and dental procedures increased to $33.8 billion, up from $13.7 billion the year prior.2 Fully electronic eligibility verifications increased to 25.7 billion in 2023 compared to 20.6 billion in 2022, and adoption of this technology is now at 94%.2

Despite the nearly 30% increase in electronic adoption in the past decade, denials related to eligibility still rank among the highest. It’s not that the technology isn’t working as intended. Many businesses don’t have the correct processes in place, or key workers are using the processes incorrectly due to a lack of training or pressure to perform their jobs quickly. A staggering $9.8 billion in time and staff savings remains on the table for providers that have been slow to adopt electronic methods or aren’t optimizing their workflow to determine accurate coverage and possible additional work. There are additional potential time-saving opportunities as well, with CAQH reporting up to 16 minutes per transaction in time savings.2

Offices need a quick and efficient process to ensure a positive patient experience. The best way to implement an eligibility verification and identification strategy is throughout the year alongside revenue cycle management (RCM) processes. In addition, staff need a strong working knowledge of how to report key information to stakeholders to ensure all workflows remain dynamic.

With the combination of technology, training on what to do with the response information, and best practices, you can establish an eligibility verification process that works for your organization.

Empower your staff to execute an eligibility strategy using technology

As a leader, you can take steps that empower your staff to build effective processes while cutting administrative costs.

First, partner with an integrated eligibility partner. Many practices find going to payer websites to verify coverage to be more efficient than spending time on the phone. With many payers available within a region, however, it can still be a clunky process to have to navigate each payers’ online portal. Finding a partner that has an automated eligibility solution with hundreds of payer connections that can integrate into your Practice Management System (PMS) can safeguard your office staff from having to browse through multiple tools or websites.

Second, perform regular updates to ensure data accuracy. Having accurate patient information is essential, and an easy way to avoid downstream denials. Your eligibility tool should be able to call out variances between your submission and payer response. It’s critical to verify patient data at every visit through e-check-in or when they arrive at the office. Further, batch payer discovery technology, which uses minimal data to scrub multiple payer inquiries simultaneously and uncover benefits perhaps unknown to the patient, can prevent denials down the road.

Third, reset office expectations about how to handle common eligibility responses and train often. Share key data points and look for ways to provide continued learning opportunities. For instance, an inactive response often has more data on where to look for patient coverage. Don’t ignore these transactions–teach your staff how to handle them efficiently.

Finally, use automation tools to increase efficiency. Applying automated front-end eligibility verifications to every claim before submission helps determine if benefits are available or denied. This automation mitigates the chance of a denial by pending or suspending claims before submission to allow for updated insurance information.

Next steps

Eligibility and benefits verification processes can be a large burden on your staff, especially if you find yourself consistently training new hires for the positions. Having manual processes also increases the likelihood of mistakes and human error. By implementing automated technology and best practices, you could save time and better support staff. You could also increase profits by bringing in revenue you hadn’t been able to collect before.

If you have questions about how to get started or want to use TriZetto products as your integrated eligibility solution, contact physiciansales@cognizant.com, or visit TriZettoProvider.com.

References

1 https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker
2 https://www.caqh.org/sites/default/files/2022-caqh-index-report%20FINAL%20SPREAD%20VERSION.pdf