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Avoid Top 5 Eligibility Mistakes for Healthy Revenue Cycle

With so many health systems trying to do more with less administrative staff, we often consult with clients to spot inefficiencies in their processes that could be eating up time. One area we’ve helped providers streamline is by making the most of their eligibility and benefits (E&B) transactions — not only how they submit them but when in the workflow and where that information gets routed.

Here we highlight five common mistakes your pre-service and follow-up teams could be making and how just a few changes could save hours in the long run.

Mistake #1: Unknowingly relying on cached responses

Do you know if your real-time E&Bs are truly real time? Some clearinghouse vendors default to a cached eligibility response to avoid wait times when a payer’s system is unavailable. The problem with this method is that you may have no way of knowing when that response was created.

If the cached response is from a patient inquiry conducted several weeks ago, there’s a chance it’s no longer accurate. In this era of Medicaid redetermination and the Great Resignation, you can’t afford to rely on out-of-date E&B responses. It puts you at risk for denials, can delay payment, and creates more back-office work.

The solution: Talk to your vendor about their caching practices and whether you can customize what you receive. Availity Essentials Pro Advanced Real-Time Eligibility caching is both optional and transparent to the user, allowing clients to achieve the right balance of speed and accuracy for their organization.

Mistake #2: Not checking E&B for all relevant service types

When a patient is scheduled for multiple visits across multiple departments, are you checking E&B for all service types? Requesting an E&B for just today’s office visit will only return those benefits, or put another way, the payer response can only answer the question you asked in the inquiry. Not checking E&B across service types limits your view of a patient’s benefits and can lead to missed co-pays, rework for front-office staff, and frustrated patients.

The solution: Requesting benefits across service types, known as service-type code (STC) splitting, returns all the most relevant information, simplifying the pre-service workflow and improving patient satisfaction. Better yet, Availity Essentials Pro Advanced Real-Time Eligibility returns multiple service-type benefits in a single 271 response.

Mistake #3: Not checking E&B for self-pay patients

Are you writing off self-pay claims before checking to see if the patient has coverage? You might be missing an opportunity to bill a payer for the encounter. Many patients who don’t think they are covered by insurance, or who present with an invalid insurance card at check-in, may in fact have active coverage. Billing a payer increases the likelihood you’ll receive payment, reduces patient collection activities, and improves patient satisfaction.

The solution: Your vendor may have a tool that automatically checks patient coverage with multiple payers. Availity Essentials Pro Self-Pay Eligibility performs this for several payers at a time, including Medicaid, using just the patient name and date of birth.

Mistake #4: Skipping that one last E&B

The patient has been seen and the claim is ready for submission — or is it? Undoubtedly, your clearinghouse will run your claim through several “scrubbing” processes to ensure a clean claim, and one of those should be sending another eligibility inquiry. This final check is best practice to ensure the patient’s benefits information on the claim matches the health plan’s record from the date of service, preventing a possible denial downstream.

The solution: Find out if your clearinghouse offers this check, and if they do, make sure it’s turned on for your organization. Availity Essentials Pro includes automated pre-claim eligibility checks as part the core service offering, contributing to our largest clients’ average 98%+ clean claim rates.

Mistake #5: Leaving E&B information in silos

Is your team accessing multiple payer sites to check E&B? If so, there’s a very good chance only some of those results are making it back to your EHR/PMS. Not only are pre-service staff slowed down by switching between workflows, but follow-up staff also must take the time to confirm benefits details. Inefficiencies like this may not seem huge in the moment, but in aggregate contribute to staff dissatisfaction and creeping denials.

The solution: Explore technology solutions that allow your staff to stay in one workflow and maintain a single source of truth for demographic and financial information. Availity Essentials Pro Advanced Real-Time Eligibility delivers complete and up-to-date benefits information integrated directly into your EHR, PMS, or HIS.

Essentials Pro, Availity’s premium, all-payer clearinghouse, empowers some of the nation’s largest hospitals and health systems with revenue cycle automation, AI, and expert client consultation.

A more robust sibling of the payer-sponsored Essentials portal you know, Essentials Pro is deeply integrated with most major EHRs and HIS’ to streamline your processes. Plus, it’s backed by Availity’s unparalleled payer connections, 20+ years of stable, private ownership, and unwavering commitment to simplifying the business of healthcare. Get to know Essentials Pro today.