Introduction

The patient eligibility verification process within healthcare is a vital step in ensuring a successful revenue cycle. Verifying insurance coverage and benefits is necessary prior to any service being rendered and prior to any claim being submitted to the payor by the healthcare provider.

Many healthcare providers continue to perform this process manually. Staff members spend hours manually navigating payer portals, verifying insurance details, manually updating records, and resolving discrepancies. While these manual workflows are extremely time-consuming, they also increase the likelihood of making errors that may ultimately lead to denied claims, delayed reimbursement and unhappy patients.

To assist healthcare providers with the issues they face, we developed an AI-Powered Eligibility Verification Platform to improve and automate the insurance verification process as part of the healthcare provider’s revenue cycle management (RCM) process. This advanced platform uses a combination of Artificial Intelligence (AI), Intelligent Data Processing, Real-Time Integrations, and Workflow Automation to improve accuracy, reduce administrative burden, and strengthen financial performance in all healthcare settings.

This case study will illustrate the challenges faced by healthcare providers, the solution we developed to address those issues, and the operational improvements experienced by healthcare providers as a result of automation.

The Challenge

The Verification of eligibility is one of the most vital steps in the healthcare revenue cycle, yet it is also one of the most labor-intensive and susceptible to human error when handled manually.

Daily, the client is processing a significant number of patient insurance verifications and their administrative staff is required to access numerous payer systems, analyze each patient’s coverage and benefits, and manually update their records prior to a potential appointment.

The client’s approach has resulted in many operational difficulties as:

• they have time-consuming manual verification
• there are frequent data entry errors/inconsistencies
• they experience delays in patient onboarding/scheduling
• limited visibility into the status of verification
• there is a disproportionate workload on the administrative staff
• the likelihood of claim denials increases due to inaccurate/incomplete information
• the organization has experienced lost revenue due to issues with billing related to eligibility verification.

Because insurance information changes frequently, the teams experienced difficulty ensuring that verification data would be accurate and current. In addition, even a minor data entry error in the verification process can lead to claim denials, delays in payment, and additional rework.

To address some of these problems, the organization needed a smarter solution to automate verification workflows, decrease errors, and give the necessary visibility of eligibility data in real-time.

Our Solution: AI-Powered Eligibility Verification Platform

Our team built a centralized eligibility verification platform that uses AI and intelligent automation to address these challenges. The aims of the project were to simplify insurance verification processes; to increase operational efficiencies; and provide revenue cycle management (RCM) teams with timelier decision-making capabilities.

Real-Time Insurance Verification

The platform provides organizations with the capability to verify patient insurance eligibility & benefits in real-time by integrating securely with multiple payer systems/insurance databases. No longer will staff members be required to manually check coverage information from a variety of sources, as they will now have access to verified data under one consolidated interface (thereby greatly reducing the time required for processing). Furthermore, all eligibility data will be available as needed so that staff will be able to make quicker and more accurate decisions about an individual patient’s eligibility/billing status.

Intelligent Data Processing

The complex process of verifying healthcare eligibility consists of processing high volumes of structured & unstructured data from many different sources. To improve these processes, intelligent data processing functionality has enabled the aggregate collection of, organization of, & validation of incoming data. The platform has the ability to identify discrepancies between two separate pieces of information, to identify missing pieces of information and will minimize manual intervention thereby improving overall accuracy throughout each step of the verification process.

Automated Workflow Management

The first priority was to reduce unwarranted administrative workloads. This platform allows management of the following activities through an automated process: There are:

• Verifying eligibility
• Verifying benefits
• Providing status updates
• Synchronizing data
• Managing exception processing workflow

By reducing manual processing through workflow management, healthcare professionals are able to spend their time supporting patients rather than processing administrative tasks.

API Integrations for Seamless Connectivity

In order to achieve seamless data communications, the platform has been integrated into the payer and healthcare application systems using secure Application Programming Interfaces (APIs). Through these APIs, real-time communications take place between each application and payer allowing for a more efficiently connected and accurate verification process as well as access to up-to-date eligibility status without having to change applications.

Centralized Dashboard and Visibility

One of the significant challenges for the client has been the lack of ability to see the verification progress and operational performance. To address this, we built a live dashboard that provides the following verification metrics:

• Status of verification
• Pending verification requests
• Completed verifications
• Exceptions
• Processing achievement trends
• Employee productivity

Through this visibility, both leadership and staff can monitor workloads, identify process bottlenecks, and make prudent operational decisions.

Scalable Infrastructure

Healthcare organizations will have different volumes of patients from time to time. The platform was created with scalability in mind, allowing the system to be able to handle everything from a small number of provider verification requests to an almost indefinite number of verification requests but maintain performance and efficiency. This is a solid foundation for future growth and operational expansion.

The Results

After implementation, the organization experienced numerous meaningful improvements in operational and financial performance.

Decreased Claims Denials

A significant achievement was the reduction in claim denials due to eligibility issues. By verifying insurance before services were rendered with greater accuracy the organization reduced claim denials which typically come from billing errors related to insurance eligibility verification. As a result, there was an improved revenue cycle and corresponding increase in reimbursement rates.

Improved Accuracy in Verification

AI-based eligibility validation and automation of data processing led to a significant reduction in human error. Staff now have access to accurate real-time eligibility data for patients so that staff can ensure that they are performing validation checks on patient records consistently and for the same reason across different systems.

Faster Verification of Eligibility

Real-time verification allows for a much quicker process in verifying a patient’s eligibility and benefit coverage. What used to take significant time through manual effort is now performed at a much greater efficiency; therefore, staff can handle more volume without increasing workload.

Increased Operational Efficiency

By utilizing automation, many previously time-consuming repetitive administrative tasks that previously took up a lot of employee hours can be eliminated.

As such, teams are able to concentrate on exception handling and patient-facing activities instead of going through the routine verification process.

Overall organizational productivity has increased as well, as operational strain has decreased for many organizations.

Improved Revenue Cycle Performance

Accurate eligibility verification is directly tied to financial performance.

By reducing denials of claims and improving data accuracy while minimizing the amount of time needed to process an eligibility verification request, the platform enabled the overall revenue cycle management process to be improved and enabled better predictability of reimbursements.

In Conclusion

Accurate eligibility verification is essential to the smooth operation of healthcare organizations and the effective operation of their revenue cycle. Unfortunately, manual eligibility verification procedures often lead to delays, inaccuracies and administrative issues for both employees and the organization.

Our AI-Powered Eligibility Verification Platform has changed this long and complicated process into a streamlined automated workflow. As a result, healthcare organizations have an eligibility verification solution that allows them to provide faster service, streamline their data, connect to other organizations and obtain centralised visibility of their information.

The result of using an automated eligibility verification solution is a faster, more accurate and more scalable way of completing eligibility verifications in support of both developing to a level of operational excellence as well as achieving long-term business growth.

Want To Modernize Your Healthcare Revenue Cycle Management (RCM) Workflows?

At Riaur AI, we build intelligent healthcare solutions that automate complex administrative processes, improve operational efficiency, and enhance revenue cycle performance. Our products range from eligibility verification automation to claims management applications to custom software development for healthcare organizations. We are here to partner with you to create scalable solutions based on your specific organization’s requirements.