Eligibility Verification and Robotic Process Automation (RPA): Five Best Practices for Process Improvements

November 1, 2021

Shot of a group of businesswomen using a laptop during a meeting at work|59% rank eligibility #1 RPA use case

Eligibility and benefit verification continues to be the most expensive administrative transaction for healthcare providers according to the 2021 CAQH Index. Tellingly, new Becker’s Healthcare research shows that 59% of health systems leveraging robotic process automation (RPA) use it for eligibility verification, making eligibility the most common process RPA users seek to improve.

Top 3 RCM Automation Targets

  • Eligibility: 59%
  • Authorization: 57%
  • Claims/follow up: 43%

We consulted revenue cycle automation expert and R1 Vice President of Automation, Lynne Hildreth, to share her insights and examples of how RPA is best used to improve eligibility processes and revenue cycle outcomes. Lynne has 25 years’ experience in the healthcare industry, including as a consultant with Deloitte and in revenue cycle leadership at Moffitt Cancer Center.

Eligibility verification affects multiple revenue cycle stages

Lynne Hildreth

Healthcare organizations use eligibility verification to confirm information such as coverage, copayments, deductibles and coinsurance with a patient’s insurance company. “Eligibility verification is an essential component of revenue cycle management,” advises Lynne. “Although typically thought of as a pre-registration activity, verifying eligibility throughout the revenue cycle is key to reducing denials, underpayments, accounts receivable days and write-offs.” With the average price of a hospital stay now exceeding $2,600 per day, failing to verify eligibility can quickly raise costs to unacceptable levels.

Robotic process automation (RPA) turbocharges eligibility verification

Software technology known as robotic process automation replicates many actions of a human computer user to complete routine administrative and clerical tasks without user intervention. Programmed software robots (bots) run continuously in the background, ensuring that predictable, repetitive tasks get performed without the need for human intervention. RPA works around the clock, executing tasks in a fraction of the time it would take a human.

“Eligibility verification is very labor-intensive with teams manually checking and re-checking numerous payer portals and websites for each patient,” says Lynne, “Automation eliminates these time-consuming, repetitive tasks and opens the door for efficient eligibility re-checks downstream, reducing denials and lowering the cost to collect.” In fact, eliminating manual verification tasks saves providers 21 minutes per transaction.

RPA best practices for eligibility verification process improvements

We asked Lynne to explain how RPA is best used to maximize reimbursement, prevent inaccurate and late payments, reduce claim edits and lessen administrative burden within the eligibility verification process.

1. Pre-registration 

Mistakes made here impact downstream, adding unnecessary reimbursement barriers and raising the risk of denials. With hospital claim denial rates steadily rising and one in four denials due to eligibility errors, automating pre-registration tasks results in fast and error-free medical insurance checks and eligibility validations. Teams can focus on more productive, satisfying work.

2. Eligibility re-check

Triggers such as a new calendar year or life event make insurance and benefits coverage changes extremely likely. Automating batch eligibility checks ensures providers have the most up-to-date coverage details. Knowing a patient’s complete coverage picture before the next service can help healthcare providers optimize care planning, deliver timelier service and give patients a more accurate cost report.

3. Additional eligibility

In addition to verifying coverage, RPA can help uncover new or additional (unknown) eligibility for patients, such as Medicare. The American Hospital Association reports uncompensated care costs hospitals billions annually, $660 billion since 2000. It is prudent to batch check your patients for additional coverage, for example, patients who have just turned 65 and are eligible for Medicare. RPA can do this quickly and efficiently without disrupting your team’s other activities.

4. Coordination of benefits (COB)

Knowing the correct sequence in which to bill payers reduces accounts receivable days, underpayments, and denials. The COB process is quite burdensome and requires consistent application of numerous rules – primary versus secondary payer, payer of last resort and many more. RPA can consistently and accurately apply those rules to every single claim, further cutting eligibility cycle times to accelerate claims processing and reimbursement.

5. Claims follow-up 

RPA can streamline claims follow-up by running batch eligibility checks on unpaid claims. Automation can quickly identify the problem if a claim is denied due to eligibility issues, allowing the healthcare provider to take faster corrective action. This lowers overall costs, relieves administrative burden and reduces delays in recovering revenue.

Expected outcomes of RPA adoption for eligibility verification

Automating eligibility verification brings meaningful improvements to more than pre-registration. RPA delivers productivity, consistency and accuracy gains to multiple eligibility processes while helping healthcare providers lower costs, reduce denials and speed up revenue collection.

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