What is Eligibility Verification?

Eligibility Verification is the process of confirming a patient's active insurance coverage for the specific date of service, determining if the plan is active, and confirming the services (benefits) covered and estimated costs. This is a critical front-end RCM task that must happen before or at the time of service, as errors at this stage are a leading cause of claim denials and bad debt.

Why Eligibility Verification is Critical for CFOs and Financial Leaders

Failure to verify eligibility is a direct cause of uncollectible revenue, making it a critical financial safeguard.

• Minimizing Claim Denials: A claim submitted for a patient with inactive or non-existent coverage is guaranteed to be denied. Real-time, automated verification is essential for maintaining a high payer net collection rate.
• Optimizing POS Collections: Knowing a patient's deductible status, copay, and coinsurance allows staff to accurately calculate and collect the patient's estimated responsibility at the time of service, maximizing the Point-of-Service (POS) Collection Rate.

Key Use Cases: How RCM Automation Transforms Eligibility

Automated Eligibility Verification is a primary use case for RCM Automation and RPA.

• Real-Time, Multi-Payer Checks: RPA bots or AI agents automatically check patient insurance coverage and benefits in real-time against hundreds of payer portals, eliminating manual effort and flagging issues before service delivery.
• Comprehensive Benefits Capture: Modern automation doesn't just confirm "active/inactive," it pulls structured data on deductibles, copays, and remaining benefits, which is vital for Patient Responsibility Estimation.

In an article from Becker's Hospital Review, Eligibility Verification Automation has a significant impact across many different areas including wait times, appointment booking optimization and helping healthcare organizations maanage patient needs without overwhelming staff.

"5 keys to enhancing automation, expanding capacity and improving efficiency to reduce costs." https://www.hfma.org/technology/artificial-intelligence/5-keys-to-enhancing-automation-expanding-capacity-and-improving-efficiency-to-reduce-costs/

Eligibility Verification vs. Coordination of Benefits (COB)

Both are part of Insurance Verification, but are distinct processes:

• Eligibility Verification confirms if a patient has active insurance coverage for the date of service.
• Coordination of Benefits (COB) determines which of the patient's multiple active coverages must be billed first (the primary).

Resources and Education

• Case Study: Candid Health's RCM Platform automates eligibility checks for Nourish, ensuring 94% of patients receive care with $0 out of pocket costs.
• How AI is Fixing Prior Authorization Denials