As administrative costs rise for healthcare organizations, automating patient eligibility verification is allowing providers ways to decrease their costs while increasing the accuracy of patient eligibility, ultimately improving revenue and claims approval results.

Robotic Process Automation (RPA) can improve patient eligibility and billing processes by assigning monotonous tasks to software bots. The implementation of RPA can provide task automation across the healthcare organization, including front-office administrative functions, operational procedures, patient interaction, and bill payments which reduce administrative costs and claim denials.

Revenue Cycle

Patient eligibility and benefits verification is one of the first steps in the healthcare revenue cycle and, unfortunately, it is also one of the first places that inefficiencies occur.

Excessive administrative expenses are attributed to various factors, including the number of providers and payers that need to interact to process benefit verification claims, and the constantly growing amount of reporting requirements, including more than 1,700 clinical quality measures collected by the Centers for Medicare and Medicaid Services * alone.

This results in providers hiring additional non-clinical workers to focus on routine process of patient eligibility verification that could easily be digitized or automated through the use of RPA or AI.

Providers can adapt AI and RPA to flow through the entire revenue cycle, starting with the initial point of contact and automating eligibility and benefit verification, prior authorizations, and claim management.

When eligibility and benefits are entirely accurate cash flow and revenue are accelerated by reducing the following issues:

  • claim denials
  • patient balances
  • manual touches (human error)

Maximizing accuracy in the retrieval and data entry to patient eligibility verification ensures that patients pay the correct copay at the time of appointment and are not billed unexpected, out-of-pocket charges that they cannot pay.

When non-clinical employees spend time on benefits verifications, their efforts would be better spent on claims denials or collections.

Watch a demo of RPA handling eligibility verification.

Claims Denial

Providers are spending excess time handling patient eligibility verification, where 25% of all denials originate, as stated by The Change Healthcare 2020 Revenue Cycles Denials Index.** A majority of revenue cycle and billing departments are consistently behind in claim rejections, which go un-appealed due to a lack of time and overworked administrative staff.

A software-powered claims management system can recover more of these denied claims with a process that automatically checks the status of submitted claims.

Many of these denied claims can be recovered with slight adjustments and corrections to the denied claim. There are multiple reasons claims are denied, and a majority of these reasons relate to simple human error in the eligibility process.

Claims are not filed on time because every claim has a specific amount of time to submit and be considered for payment.

Neglecting to submit a claim before its due date often results in healthcare professionals paying for it at their own expense.

Inaccurate insurance ID number on the claim because old insurance cards and ID numbers submitted on a claim may not be recognized by an insurance company.

Each time a patient visits a provider’s office, they are responsible for updating and verifying their current information and any changes to their insurance.

Non-covered services result in a denial because, according to payer policy, a service may not be considered medically necessary due to the diagnosis submitted on the claim.

Even though a patient was treated based on the provider’s documentation, the actual diagnosis may not have been communicated to the facility’s coding and billing department.

Coordination of benefits between multiple insurance plans when patients have numerous payers, providers may not submit or coordinate billing correctly between multiple payers.

Incomplete Information Claims may lack correct and necessary patient and insurance information, incorrect data or numbers, and misspelling. 15% of denials are a result of incomplete information. Manual input and failure to verify data are two of the biggest reasons for these inaccuracies.

A denied claim means delayed or lost revenue and additional burdens on resources. While one claim denial may not appear to have much financial impact, the cumulative effect of these denials can result in staggering revenue loss. An AI-powered denials management system will flag a claim as denied and automatically address any simple errors, and then resubmit the claim.

For more complex errors, AI can pass the denial to a human but will provide detailed patient information and denial information, significantly speeding the rework time. The AI-powered management system will rework all denied claims, thus increasing revenue and allowing non-clinical staff to focus energies elsewhere.

Save Employee Time

Another problem posed by today’s manual patient eligibility verification checks is the employee time burden. These tasks affect non-clinical staff and physicians and leave less time for patient care. The Annals of Internal Medicine*** found that physicians spend just under one-half (49.2%) of their workday on electronic health records (EHR) and administrative tasks, and just 27% of their time on clinical face time with patients.

When AI and RPA systems are employed in healthcare facilities, providers and non-clinical staff can minimize routine and rote processing tasks. This prioritization will allocate resources to tasks that require human analysis and intervention so staff can focus on these exceptions that require additional judgment.

Credit balance adjustment is a time-consuming process and involves the application of credit balances and adjustments to patient accounts that must be done in a timely fashion.

RPA can help reduce this risk as a secondary benefit to improving productivity. Bots can identify the same payments from the same health plan and then process the transaction, crediting the appropriate patient account each time. Reversing credit balances using bots instead of manual processing can save a significant amount of time.

Prior authorization is the task necessary to clarify, request, and obtain coverage for specific services. According to Fierce Healthcare**** fully electronic, prior authorizations take just four minutes on average to complete, versus 21 minutes to complete manually, a nearly 80% improvement.

A highly productive prior authorization department can significantly increase operational efficiencies, reduce costs, and slash denials.

When PALTC providers utilize artificial intelligence on their patient eligibility verification, accuracy is improved while freeing employees time to focus on other tasks.

Decreasing unnecessary administrative tasks that AI and RPA systems can complete with a higher accuracy rate and efficiency enhances patient care and satisfaction within the healthcare facility.

RPA can lead to better care outcomes and improve the productivity and efficiency of care delivery. It can also improve the day-to-day life of healthcare practitioners and non-clinical staff, letting them spend more time looking after patients and focusing on critical tasks, raising staff morale, and improving retention.