Eligibility and Benefits Verification and Prior Authorizations: Challenges and Automation Success Stories
The health of your revenue cycle begins with patient access. From the first patient encounter through payer reimbursement and patient payments, improvements to revenue cycle functions performed at patient access—including eligibility and benefits verification and prior authorization—can impact the overall quality and effectiveness of your revenue cycle.
Providers are continually being asked to do more with less. Patients are demanding greater transparency as well as more convenient options. Payers are tightening their requirements and denying more claims than ever. On top of it all, staffing shortages and turnover have added additional stress to already overworked staff.
In this blog post, we explore some of the challenges, emerging technologies, and success stories surrounding eligibility and benefits verification and prior authorization.
Challenges to Revenue Cycle Functions at Patient Access
Many patient access and revenue cycle processes are manual or tied to siloed and/or disconnected systems. Lack of payer connectivity or automated processes translates to time-consuming calls to payers or searching payer websites for information.
Thus, identifying and requesting eligibility information is time-consuming and labor-intensive, plus prior authorization requirements vary from one payer to the next. The complex nature of authorizations increases the likelihood of human error and missed patient care. These delays impact claims processing, leading to delayed reimbursement and denials.
- 41% of denials are caused by front-end revenue cycle issues (registration/eligibility, authorization, medical necessity).[1]
- While registration/eligibility has seen the biggest decrease in denials by category since 2020, it is still the top cause at 22%.[2]
- 19% of denials are due to issues with medical necessity or authorization/pre-certification[3]
In addition, staffing shortages and turnover are endemic in the healthcare industry with nearly 75% of medical practices say staffing will be their greatest challenge for 2022.[4] Revenue cycle staff, especially coders and billers, are in short supply.[5]
Many patient access staff work long hours at low wages, making turnover an issue. Staff turnover can lead to inconsistent quality and poor patient experiences. Plus, entry-level workers lack experience and knowledge of how their job impacts the revenue cycle. Furthermore, a lack of on-the-job education can lead to errors, and registration errors are a top cause of denied claims.
With challenges like these, health systems and providers are beginning to explore their patient access options—including automation and emerging technologies.
Leveraging Technology to Improve Patient Access
Robotic process automation (RPA) and BOTS (short for “robots”) can be used to automate eligibility and benefits verification, reducing eligibility or benefits-related claim denials. BOTs by Omega Healthcare can process more than 2,500 verifications per hour and identify claims denied due to issues with eligibility or benefits.[6]
In support of prior authorization, BOTs perform pre-verification of document availability, remove claims missing authorizations from production, notify clients of the missing authorizations, follow up on open authorization document requests, and update systems once documents are received. The result is a 25% reduction in per-claim processing through the elimination of calls with payers and an ability to redeploy staff to higher value tasks and more focus on patient care.[7] But automated systems require oversight and strong development—and cannot exist alone. That’s why some health systems are leveraging the expertise of others by turning to outsourcing.
Health System Successes with Outsourcing
For providers looking to spend less time on the phone with payers and more time with patients, outsourcing eligibility and benefits verification and prior authorization can be an attractive option. Outsourcing these administrative areas is not as common as for other revenue cycle functions but can be very beneficial. Below are two success stories that show the value of outsourcing to Omega Healthcare clients.
Success Story: BOTS Improve Eligibility and Benefits Verification
First, a large provider with more than 400,000 patients found managing eligibility and benefits verification to be an ongoing challenge. Its agents spent hours on the phone calling payers or on payer portals searching for coverage information. Looking to make the process more efficient and effective, they partnered with Omega Healthcare to automate the secure retrieval of eligibility and benefits information through an API/BOT-based approach that enabled offline eligibility verification. Even with a vast inventory, eligibility and benefits verification took only minutes. The technology removed the potential for human errors and improved the speed of securing eligibility and benefits information—and ultimately, the partnership helped ensure on-time, full payments.
Read the Eligibility and Benefits Verification case study here.
Success Story: Bots Improve Prior Authorization
Another large, national healthcare company with thousands of clinics nationwide needed to automate and improve the time-consuming and labor-intensive prior authorization request submission process. The company partnered with Omega Healthcare using BOTs to perform pre-verification of document availability, remove claims missing authorizations from the production bucket, notify clients of missing authorizations, follow up on open authorization document requests, and update systems once documents were received. As a result, the company streamlined its authorization request submission process and was able to better serve its patients, improving patient care delivery and speed of reimbursement.
Read the Prior Authorization case study here.
These stories help demonstrate how outsourcing insurance eligibility and benefits verification and prior authorization can help providers reduce denials and rework, maximize coverage discovery, and improve staff productivity.
Dedicated Teams and Innovative Technology Set Omega Healthcare Apart
A trusted partner that helps improve financial outcomes through technology and clinically enabled transformational solutions, Omega Healthcare’s flexible portfolio of platform-based services are tailored to the unique needs of its clients.
Omega Healthcare’s dedicated team of insurance experts and automation capabilities that leverage API and BOT technologies can streamline eligibility and benefits verification.
Omega Healthcare’s dedicated team of insurance experts and automation capabilities that leverage API and BOT technologies through ODP-CONNECT can streamline eligibility and benefits verification and prior authorizations. We can deliver complete eligibility and benefits information up to four hours before a patient’s visit, and large batch verifications can be completed in just minutes. Our insurance experts leverage multiple tools to gather information, including phone, payer portals, email, fax and more, saving your staff time and freeing them up to focus on delivering patient care. These efforts result in fewer denials and write-offs and more appropriately paid claims, faster.
Similarly, Omega Healthcare’s team of dedicated prior-authorization specialists can manage the entire process, including medical necessity and referrals. Our proprietary library of more than 1.5 million payer-specific rules enables our team of experts to stay up to date on ever-evolving payer requirements. We can deliver prior authorizations within 2-5 days and referrals within 24 hours, helping your team reduce prior-authorization and medical necessity-related denials and improving staff efficiency.
[1] “The Change Healthcare 2022 Revenue Cycle Denials Index,” Change Healthcare, accessed via web January 23, 2023
[2] Ibid.
[3] Ibid.
[4]“Workarounds for worker shortages: 8 strategies for pandemic staffing issues in medical practices,” MGMA Stat, September 29, 2021
[5] “Revenue cycle directors deal with a competitive market for staff as elective care returns,” Morse, Susan, Healthcare Finance, June 21, 2021.
[6] Omega Healthcare, internal data.
[7] Ibid.