Insurance and revenue
Insurance eligibility verification, finished before the patient arrives.
Every upcoming visit checked automatically, with copay, deductible and coinsurance written to the chart before the patient arrives.
Eligibility result, Maria L., Thu 9:40
- Plan
- Commercial PPO
- Network
- In network
- Office copay
- $30
- Coinsurance
- 20%
Deductible met
$850 of $1,500
Out of pocket met
$1,240 of $6,000
- Prior auth for this visit
- Not required
- Secondary coverage
- None reported
- Written to chart
- Copay, deductible, coinsurance
Checked 48 hours out, checked again this morning. Nothing for staff to do.
A coverage problem found before the visit is a phone call. The same problem found after the claim is a denial, an appeal, and a patient who thought they were covered.
10–15 min
of staff time per manual check, removed
0
copay surprises at the front desk
Where coverage actually gets checked
The check is not skipped because it is hard.
It is skipped because it lands on the busiest person at the busiest hour of the day it is needed, and a patient standing at the desk always wins that argument.
How a month of checks comes back
The bottom two lanes are the whole reason to check early.
Three ways a check gets run
On the call, on every booking, or overnight.
Practices usually need all three, because coverage does not go unchecked for one reason. Some of it is never captured, some is captured and never used, and some was right when it was captured and has since changed.
Checked while the patient is still on the line
The payer and member identifier are collected conversationally and confirmed back, which is where most bad identifiers get caught. The check then runs against what was captured, so a wrong digit surfaces as a question the patient can answer rather than as a rejection six weeks later.
The identifier is read back first
Confirming it with the person holding the card catches a transposed digit that nothing further down the line can.
A failed lookup stays a conversation
If the identifier does not resolve, the caller has not hung up yet and can simply read the card again.
What the morning looks like
Tomorrow's schedule, already sorted into done and not done.
Every visit on the next day's book has a status before anyone logs in. The rows that need a person are the only ones with anything left to click.
Tomorrow, Fri: 38 visits
| Patient | Status |
|---|---|
| Maria L. | Working |
| James O. | Working |
| Priya S. | Working |
| Daniel K. | Working |
| Rosa M. | Working |
| Tom W. | Working |
35 of 38 closed overnight. 3 rows need a decision.
From card to estimate
Five checks between a member ID and a number you can quote.
A plan being active is the first answer, not the last one. The work that prevents a denial sits in the steps after it.
James O., visit Fri 9:00
- 1270/271
Coverage found
Payer ID matched
- 2
Active
Effective 01/01, no term date
- 3
Benefits read
Copay $25, deductible met
- 4
Payer order
Medicare Advantage primary, retiree plan second
- 5
Estimate ready
$25 due at check in
Every step is written to the chart as a field, with the raw reply kept for audit.
When the card is missing
A photo of the card, read while the patient waits.
No card on file means a text, not a phone call. The patient takes two photos and the fields arrive as a draft your team approves.
Texted insurance form, Daniel K.
Card photo, front
STATE MEDICAID MANAGED CARE
Member: DANIEL K
ID: MCD 7731 0094 2
Group: 00412
PCP: Riverside Family Medicine
Member services: (555) 010-4418
Draft waiting for staff approval. Eligibility runs once approved.
Score your process
How much of your schedule goes unchecked.
Your verified share, your coverage denials and the minutes a check takes your staff, weighted into a single number, with the money that sits underneath it.
Score your own eligibility process
Six numbers most practices already know. The score is built from the first four, weighted as shown underneath.
46
out of 100
Patchy
Verification score 46 out of 100. Patchy.What that means
Checked when somebody has a minute, which is most of the problem.
- Visits a month with no check
- 495
- Coverage found out afterwards, if at all
- Denials a month a check would catch
- 38
- About 70% of the unchecked ones
- Staff hours back a month
- 47
- $15,876 a year at the rate you set
- Revenue protected a year
- $81,648
- Before any rework or appeal cost
Coverage is weighted 55 of 100, coverage denials 30, and minutes per check 15. Denials counted as preventable are capped at the number of visits you do not check, then reduced to 70%, because a check before the visit catches a lapsed or switched plan and a wrong member ID, not a payer changing its position. Your own figures will differ.
The difference
Two ways to find out a plan has lapsed.
Both practices end up knowing the same fact about the same patient. One of them learns it while it still costs a phone call.
Found after the claim
Found before the visit
When cover is checked
On the day, if somebody has a spare minute
At booking, then again as the date gets close
The patient has switched plans
You find out when the claim comes back
You find out in a call they can still act on
A digit wrong in the member ID
Rejected weeks later with no useful reason attached
Read back and fixed while they are still talking
What the patient is responsible for
Guessed at the desk, then corrected by letter
On the chart before they walk through the door
What your team opens in the morning
The same list as everyone else, unsorted
Only the visits that need a person
What the mistake costs
Rework, an appeal, and an awkward call about money
One check
Where this stops
A coverage check is not an opinion about benefits.
That distinction is the whole safety story here. A patient who is told the wrong thing about their own cover remembers exactly who told them, and so does their employer.
What it will do
- Collect the payer and member identifier, then confirm both back
- Check whether the plan is active for the date of that visit
- Write plan status and patient responsibility onto the chart as fields
- Raise a lapsed or switched plan while the patient can still fix it
- Hand anything ambiguous to your billing team with what it found
What it will never do
- Telling a patient whether a procedure is covered
- Quoting a final out of pocket figure as though it were a bill
- Deciding that a visit should not go ahead
- Guessing at a plan when the identifier will not resolve
- Chasing prior authorisation or arguing with a determination
Anything the check cannot answer plainly is routed instead of approximated, because an approximation said out loud to a patient becomes a promise.
See it work
Coverage confirmed before the patient arrives
Deductible, copay, coinsurance and whether the MRI needs prior auth, all from one payer call, with the reference number on file.
Insurance and revenue
The rest of the workflow.
Before it touches a claim
What billing teams want settled first.
Confirming, before the patient is seen, that their plan is active for the date of that visit and what the plan says they are responsible for. Done in advance it costs a phone call. Done after the claim comes back it costs a denial, an appeal and a difficult conversation.
Yes, the two names describe the same job. Some practices and systems call it one thing and some the other, and both mean checking cover before a visit rather than after a claim.
When the appointment is made, again closer to the date if it was booked a long way ahead, and across the following day's schedule overnight. The automatic version stays off until your practice turns it on.
In the chart, as the fields your billing process already reads, rather than as a note somebody has to go and open. Plan status and patient responsibility are written where your team expects to find them.
Yes. You set a monthly ceiling and watch the count against it, then choose whether hitting it warns your team or halts further automatic checks until you say otherwise.
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