Currently, medical technology is all about networking with different frameworks and sophisticated software solutions to optimize processes, save time, and increase revenue. There are various electronic alternatives available to verify patient eligibility, and each one of them will affect the revenue stream in one way or the other. The most popular one is that which provides real-time eligibility verification through a web portal that all stakeholders in the medical and healthcare sector can log on to, to update and access information.

The main objectives are to make eligibility verification real-time, error-free, cost-effective, and speedy. The method of verification adopted can vastly improve the pace of payment for both provider and payer. It is a well-known fact that a manual check takes more time than electronic verification, and real-time eligibility verification helps to cross-check, confirm and update patient data online, thus enhancing the revenue cycle management at a healthcare facility.

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What is Real-time Eligibility Verification?

Real-time eligibility verification helps us access information on the coverage dates of the patient’s policy; if customized right, it can also provide comprehensive details on the insurance including co-pay and deductible status, an estimate of out-of-pocket expenses, likely billing amount as well as “extras” that the patient may have to shell out depending on the choice of therapy.

Doing the verification real-time essentially means the healthcare facility does not “blindly accept” the data provided by the patient. In fact, real-time eligibility verification can be done even before a patient visits the facility. The help desk staff vets the payer's eligibility details through the customized software solution, to auto-generate the correct patient demographics; this negates the need to re-key patient data.

Thus real-time verification procedures restructure the patient admission process.

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How Does Real-time Eligibility Work?

Different stakeholders in the healthcare system, including providers, payers, and pharmacists are trying to synchronize the patient information collected at the desk with backend systems and a network of insurers to speed up eligibility verification. This sort of check will cut down on costs, improve patient experience and enhance health outcomes.

In fact, patient eligibility verification software may be customized to suit different needs. These days AI and machine learning solutions help to collate payer-remit data, identify claim denial risks in advance, and provide alerts if corrective action is not initiated. This helps to make staff more proactive as there is accountability. Use of real-time eligibility verification thus reduces denials.

Real-time eligibility verification allows direct verification of insurance coverage, including details on all or many of the following:

Medicare and Medicaid health maintenance organization (HMO)
Type of medicare coverage
Coverage dates
Patient demographics
Benefit options – including patient responsibilities for co-pay, co-insurance & deductibles,
Total and remaining deductible amounts and co-pays
Referrals and pre-authorizations
Claims mailing address
Lifetime maximum
Address for claims submission
In-network or out-of-network status
Durable medical equipment coverage

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Real-time eligibility software gathers all data as information inputs; it will record necessary and crucial details like:

Spelling of the patient’s name
Date of birth
Address
Social security number
Insurance carrier name
ID number
Group number
Type of plan and coverage details
Patient policy status and effective date
Plan exclusions
Payable benefits

These are then approved electronically and sent to medical coverage payers on the software system; the software application then authenticates payer response and obtains eligibility results in real-time as mentioned in the previous listing
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Traditional Eligibility Verification vs. Real-time Verification

Eligibility verification is the second phase in the revenue cycle management and apparently, the most significant. In traditional eligibility verification, there is no effective verification procedure as it is difficult to contact payers and decide on the payer/patient payment responsibilities. As a result, the number of errors made during claims submissions are many.

Traditional eligibility verification may delay or skip your normal A/R days and reduce the monthly income. Verifying patient eligibility by checking individual payer entries or through multiple phone calls is very tedious and delay timely and effective patient access to treatment.

A real-time verification process which is available through a single portal is considerably more effective. It streamlines communication with payers and gives quick eligibility responses, which means your team can verify the insurance coverage in mere seconds, not hours or days. With the right real-time eligibility verification tool, healthcare providers can utilize highly efficient workflow to communicate with almost all types of insurance payers.

Eligibility outputs are immediate, simple to read, and contain significant co-pay and deductible information. These services will enable you to decide if a patient is eligible and what their insurance coverage details are even before they visit the healthcare provider office. There is no waiting time involved, as the provider no longer needs to struggle with computerized Interactive Voice Response (IVR) systems to check a patient's eligibility benefits; it saves time for both providers and payers thus enhancing collections.

‍The Benefits of Real-Time Eligibility Verification

‍Healthcare practices depend overly on front office staff to manage payments collection and eligibility verification; however, they are not provided the best tools for executing these tasks. So they fall back on convoluted traditional methods of verification which do not yield the desired results.

According to the American Association of Professional Coders, the top three reasons claims are denied are:

Incorrect or partial patient information
Expired insurance coverage
Excluded services
Prior authorization required

Most of these challenges may be addressed with the use of real-time insurance eligibility verification software.Let us discuss some of the benefits of real-time eligibility verification:

Increased Claim Pay-outs

‍A successful claim submission process begins the moment a patient walks into the healthcare facility or calls for an appointment. With real-time eligibility verification, this is quite possible, as also are timely and reasonable pay-outs. Medical practices need to take full benefit of simple, inexpensive software applications that let the front office/ reception speed up the registration of the patient without losing any information; this helps to increase claim pay-outs.

Enhanced Cash Flow:

‍Fluctuating plans and high patient deductibles make the task of verifying insurance coverage and benefits time-consuming and complicated.The most ideal approach to combat this challenge is to utilize the tools which are built in the Electronic Data Interface (EDI), which can verify patient's insurance eligibility and benefits on a real-time basis. This greatly helps to enhance revenues. If your Electronic Health Record (EHR)) system is reliable and error-free, automatic verification of coverage on a daily, weekly or monthly basis is possible with a mere click.

Patient Satisfaction:

Electronic real-time eligibility verification streamlines the overall front office process - decisions on eligibility, coverage, and benefits can be taken after a quick check with most payers. Immediate checks reduce risks like patient's plan expiry, lack of coverage of a particular procedure, and so on, which directly impacts patient satisfaction.
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To Summarize

‍With real-time eligibility verification set up properly, the front office staff will be free from a large number of day-to-day vexed issues. For the patient, too, quick processes and flawless payment procedures enhance customer experience. All the benefits of real-time eligibility verification, therefore, affect a healthcare practice's bottom line, in a positive manner.

Article by

Susan Collins

Susan is an experienced revenue cycle management (RCM) professional with extensive writing expertise. She excels at managing complexities effortlessly with a strong background in healthcare billing and reimbursement. Susan's proficiency spans various specialties, consistently providing valuable insights and tailored solutions. She specializes in coding compliance, claims processing, and revenue optimization. As a prominent writer in the RCM space, Susan delivers concise and practical advice, empowering healthcare organizations to confidently navigate the financial aspects of patient care.