Eligibility & Benefits Verification Automation
We automate patient insurance checks, capture coverage and benefit details, and record the results in your systems. Your team reviews the exceptions instead of processing every patient manually.
Illustration of an eligibility verification run. Three scheduled patients are checked with their payers. For two, coverage and benefit details are captured and each record is marked verification completed. The third has a member ID that does not match the payer's records, so it is routed to staff review.
How PTCoA automated eligibility checks
Their staff checked insurance in several payer portals for every visit, then copied the results between the EHR and the billing system by hand. Now every new appointment starts a check automatically: coverage, copay and deductible are verified, saved in the EHR (PrognoCIS) and sent to billing (TriZetto). Inactive coverage and missing IDs go to staff.
Measured results
The case study also reports 100% ROI in 23 days for this eligibility automation together with Denial Hunter, our denials automation, and $180,000 in projected savings for the first year.
Another client cut each check from about 5 minutes to about 1 minute, across several payer portals. Read the case study
Every step of an eligibility check.
An eligibility check is a series of small, repetitive tasks. These are the ones we automate.
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01Prepare
Get every patient ready for a clean check.
- Find the patients to check in your schedule, new orders or work queues.
- Pull each patient's details, insurance, member ID and date of service.
- Flag missing information before checking with the payer.
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02Verify
Ask the payer and capture the answer.
- Check eligibility with the payer through a direct connection, a clearinghouse or the payer's portal.
- Capture coverage status, plan details and coverage dates.
- Capture copays, coinsurance, deductibles and other benefits the payer returns.
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03Record
Put the result where your team works.
- Save the results, or a standard note, in your system.
- Note where and when each check was done.
- Keep a copy of the payer's response if your process requires it.
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04Resolve
Hand off what needs a person.
- Send inactive coverage, mismatches and failed checks to your staff.
- Retry checks that failed for a temporary reason.
- Check again before the visit, or when details change.
- Keep track of finished and open cases.
We set up the workflow for your systems, payers and rules. Your team only handles the cases that need a person.
An eligibility check shows what the payer reports at that moment. It doesn't guarantee that a claim will be paid.
Sending prior authorization requests is a separate workflow. Patient cost estimates, finding unknown coverage and checking whether a service needs authorization can be added if they fit the project.
Eligibility automation usually pays off when most of these are true.
- You check eligibility for many patients every day.
- Staff look up the same patient in several systems and payer portals.
- Results are typed into patient records by hand.
- Most checks follow the same steps, and you know which cases need a person.
What affects your savings
- How many eligibility checks you do each month
- How long each check takes by hand
- Which payers you can reach, and how
- How many checks still need a person
- What it costs to build and maintain
The return is different for every organization. Schedule a call and we'll give you a quick, honest estimate of whether it's worth it for yours.
Schedule a callThe automation works between your systems and your payers.
Your staff keep using the systems they know. We pick the method for each step: a direct connection or clearinghouse where one exists, UiPath or Python where the work happens in portals and desktop apps, and AI where a response or document needs reading.
Example of the automation between three places. It reads tomorrow's schedule from the EHR, checks each patient with the payer through a portal or clearinghouse, and saves the result back to the EHR. A patient whose member ID is not found is sent to the staff review queue with the reason.
Monitored and maintained by us. We watch every run and update the workflow when payers or your systems change.
Patient data (PHI)
What happens to your patient data
Your data is safe.
- Where it runs
- On a machine you own: usually a virtual machine on your side, or your own AWS or Azure account.
- What we store
- We don't store patient data. The automation reads it, uses it and writes the result back. In the rare case PHI has to be in transaction data, it's encrypted.
- Who can access it
- Only the developer who builds and maintains the automation. On your machine, you decide who else gets access.
- What we sign
- A BAA before we see any patient data. AI runs on AWS, Azure or Google under BAAs, and your data isn't used to train models.
Is automating your eligibility checks worth it?
Book a 30-minute call with Karl, our CTO. If you'd rather write, send us a message.
Walk me through how you check eligibility now. I'll tell you which parts we can automate, what it would cost, and whether it's worth doing.
Karl