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patient eligibility verification

The Role of Technology in Patient Eligibility Verification for Practices

When a patient schedules an appointment in the healthcare industry, one of the first steps in the revenue cycle is patient eligibility verification and benefits verification. Accurate verification is essential to prevent denied claims, scheduling errors, and adverse patient experiences. However, the process is costly for medical practices, with a 16% increase in spending in 2021 due to manual verifications for COVID-19 job losses and telemedicine. Leveraging artificial intelligence capabilities to automate insurance eligibility verifications is becoming more critical than ever before to avoid inaccuracies and save money.

What Is Patient Eligibility And Benefits Verification?

Patient eligibility verification is the process of confirming a patient’s coverage for medical services and determining their responsibility for payments. Healthcare practices can verify health plan coverage, copayments, deductibles, and coinsurance. This process helps prevent claim denials and enables the proactive collection of patient payments. Organizations may refuse treatment to individuals who don’t meet eligibility requirements to avoid liability lawsuits due to missed diagnoses or delayed treatment. Medicare eligibility verification is necessary to determine if patients have all their insurance benefits and if services can be covered. Hospitals must also verify eligibility for private-pay patients. The type of verification required depends on the payer for the medical care.

Best Practices For Patient Eligibility and Benefits Verification

  • Verify the active status of insurance plans and mark accounts accordingly.
  • Remind patients to update their COB with each payer and verify primary, secondary, and tertiary insurance.
  • Verify if patients 65 or older have traditional Medicare coverage.
  • Confirm covered services under the patient’s insurance policy and whether a referral or prior authorization is required.
  • Ensure that referrals and authorizations are approved, entered into the system, and linked to the correct visits.
  • Check for benefit limits and dollar amount limitations per visit, service frequency, and time frame.
  • Determine copayment, coinsurance, and deductible amounts.
  • Collect as much demographic information as possible, including preferred language, race, ethnicity, and date of birth.
  • Always check if the patient has a change in insurance or coverage.

Benefits Of Technology In Patient Eligibility Verification

The healthcare revenue cycle is burdened with many inefficient, repetitive processes contributing to administrative waste. Intelligent automation through AI is a clear solution to these issues. Technology has streamlined the patient eligibility verification process, allowing healthcare providers to quickly and accurately determine a patient’s insurance coverage and benefits. Automated eligibility verification systems can reduce the risk of errors and ensure that patients receive the needed care. Here are the following benefits of using technology for the eligibility verification process:

Reducing Claim Denials

Automating eligibility and benefits verifications through intelligent automation can significantly reduce claim denials. Denial management is a significant issue in the healthcare industry, leading to increased workloads and costs. Registration and eligibility are among the top reasons for claims denials, causing nearly 27% of all denials. Benefit checks can be done more frequently and accurately automatically than manually. This reduces upfront errors, preventing subsequent denials and decreasing the burden on employees and patients.

Saving Employee Time

Manually checking a patient’s eligibility for insurance benefits is a time-consuming task that can take up to 21 minutes per transaction. By deploying technology to automate eligibility verifications, hospitals can reduce their employees’ time on these repetitive and mundane tasks. This frees their employees to focus on more complex and critical tasks, ultimately reducing employee burnout and increasing job satisfaction. With the accuracy of AI, there is a reduced likelihood of downstream errors such as denials, which also saves time and resources for medical practices.

Increase First-Pass Claim Acceptance Rates

One of the primary benefits of automating eligibility and benefits verifications is the increased first-pass claim acceptance rates. Clean claims ensure quick payment for services provided, and avoiding rejected or denied claims is crucial to revenue cycle management. Organizations can see significant improvements in their first-pass claim acceptance rates when they implement automated eligibility verification processes, from 90% to 98%, resulting in reimbursements receiving 15% faster. 

Prevent Fraud And Identify Theft 

Technology can prevent fraud and identity theft in inpatient verification by implementing biometric identification systems. Biometric identification systems use unique physical or behavioral characteristics, such as fingerprints, facial recognition, or iris scans, to verify the identity of patients. This method is much more reliable than traditional methods, such as ID cards or social security numbers, which can be easily stolen or forged. In addition, automated eligibility and benefits verification systems can flag inconsistencies or errors in patient information, helping to catch fraudulent activity before it leads to financial loss. These systems can also use artificial intelligence and machine learning algorithms to identify patterns of fraudulent behavior and prevent it from happening in the future. Overall, technology provides more secure and accurate methods of patient verification, reducing the risk of fraud and identity theft and protecting both patients and healthcare organizations.

Improving the Patient Registration Process

New patient registration is crucial in providing healthcare services, but it can take time and effort. Verifying insurance at the front desk can take significant time, leading to long waiting times and reduced patient satisfaction. By implementing insurance verification software, the process can be significantly improved. The software is more capable and faster than manual validation, allowing for a streamlined registration process. As a result, staff time can be freed up for other tasks, and patients can experience shorter waiting times and a more efficient registration process.

Improving cash flow 

Accurate patient eligibility verification can help speed up cash flow by reducing claim denials, patient balances, and manual touches. Claim denials slow the reimbursement process, while accurate benefits verification ensures patients pay the correct copay and avoid unexpected charges. Manual eligibility and benefits verification processes can take up valuable employee time, which can be redirected to tasks that improve cash flow, such as working on denied claims and following up on patient balances. By improving these processes, health systems can scale back administrative hiring while growing as an organization.

Improving Compliance with Regulations

Compliance with healthcare regulations can be a challenge for healthcare providers, and failing to meet these requirements can result in financial penalties. Technology can help ensure compliance by automating processes and providing data management and reporting tools.

For example, many regulations require providers to protect patient data and ensure secure electronic health records (EHRs) transmission. Technology can provide encryption, firewalls, and secure portals to ensure compliance with these regulations. Additionally, technology can automate appointment reminders, follow-up care, and billing processes, which can help providers stay on top of regulatory requirements.

Increasing Patient Engagement 

Mobile applications have revolutionized the way patients interact with healthcare providers, allowing for increased engagement and better patient outcomes. With mobile apps, patients can access their medical records, schedule appointments, communicate with their providers, receive reminders for medication, and track their progress, all from the convenience of their smartphones.

These apps give patients greater control over their healthcare, resulting in increased engagement and improved patient satisfaction. Patients more engaged in healthcare are more likely to follow their treatment plans and achieve better outcomes. Additionally, mobile apps can reduce the burden on healthcare providers, allowing them to focus on more complex cases and improving overall efficiency.


The patient eligibility verification process must be noticed, as medical practices aim to provide timely and suitable care. Identifying the right coverage and ensuring the best possible medical treatment for patients is crucial. AI-powered revenue cycle management solutions offer significant benefits for healthcare organizations, including increased efficiency, improved financial stability, and better patient satisfaction. By embracing AI technology, healthcare providers can stay ahead of the curve and remain competitive in an ever-changing healthcare landscape.

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