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5 Ways To Improve Your Patient Eligibility Verification Process

There can be several reasons why a claim may get rejected. Some of these reasons could be unpreventable. However, one reason that definitely can be proactively avoided is ineligibility.

Eligibility verification is one of the most basic RCM steps that many Revenue Cycle Management companies don’t manage to capture right. Since this is one of the initial steps of RCM, when eligibility verification doesn’t happen right, the proceeding steps go haywire too.

If your claims’ rejection or denial rates have been consistently high, the first thing for you to do is try and pinpoint the reason for rejections and denials.

Let’s say you identify that lack of coverage or ineligibility is a reason for these high denial numbers. In that case, that is the first thing you should tackle as a healthcare provider who wants to sustain in business.

Here are five proven ways to improve the patient eligibility verification process.

1. Starting in advance

The best way Revenue Cycle Management companies can handle eligibility verification is to start early on. When a patient calls about an appointment, the basic details are collected, including insurance coverage, coverage number, and other demographic data.

This is useful in multiple ways. By starting eligibility verification early, you are well-prepared for the patient when they step in for your service.

In case there is a problem with eligibility, you can sort it out with the payer or the patient before services are rendered.

Having everything ready for the patient before they come in helps improve the patient experience, which is something all practices want.

2. Investing in automated front-end tools

This is very important if you want to streamline the eligibility verification process and ensure no steps are missed every time a new patient is set to visit your practice or clinic. Every time a new patient is set to visit the practice, your team should ideally check if the patient is covered by insurance, if the services requested are specifically covered, and if the basic information the patient gives matches.

Now, imagine your practice sees high patient inflow. A single front-end member cannot verify multiple details consistently. This is a tiresome and extremely monotonous task.

Revenue Cycle Management companies with automated tools to handle initial verification details fare better because the process happens quickly and requires minimal manual effort.

Rather than verifying every detail the patient provided, the RCM team can focus on other critical RCM steps.

3. Working with Revenue Cycle Management companies that have custom documentation processes

Documentation is a vital end step for eligibility verification. You could have verified all the necessary details. However, if these data are not recorded and documented, then you may not be able to submit them right to the payer at the end. So, talk to your verification team to find out if they have consistently followed up with documentation.

Also, different practices require different kinds of information to be documented. For instance, a pathology lab will require different documentation when compared to a critical care unit or a substance use support center. That’s why Revenue Cycle Management companies need to custom-create their documentation processes depending on the clients they have.

Does yours do it? Talk to Quintessence to know how our processes can improve your eligibility verification and documentation steps and bring a difference in the denials rate and patient experience.

4. Focus on smaller details

Some patient plans may require prior authorizations, while others may need the patient to go through a predetermined number of visits before the coverage kicks in. All these are smaller details that may not be valid for all patients. However, these could be reasons why a patient’s claim gets rejected by the payer.

If you provide services to a patient without checking these details, you will have to pay the penalties for lost revenues in the future. So only engage with Revenue Cycle Management companies that understand these nuances and help tighten the initial eligibility verification process to block all possible revenue leaks.

5. Have a team that’s on its feet

In a process like patient eligibility verification, time is everything. The eligibility verification should happen quickly, efficiently, and with precision, so everything else moves smoothly. You may have worked with Revenue Cycle Management companies in the past that had a set process of eligibility verification and rarely strayed away from it. Here is where a smart and proactive team comes to help.

When you work with Quintessence, you will know how outdated that is. Our team is built to handle stress and work quickly. Our eligibility verification team is backed by AI tools that help them move through processes confidently and precisely that not everyone can afford to have.

You can see our team making calls to patients to quickly get missed information or get in touch with people from the payer’s end to sort out issues amicably instead of waiting for emails to get answered, which may take days together.


Improving your patient eligibility verification process is a multi-step change. Revenue Cycle Management companies need to make the right investments in tools and techniques, train employees to handle verifications processes more effectively, and have a team that’s quick to spot issues and get explanations before services are rendered.

When the eligibility verification is done right, the rest of the RCM processes fall in place easily too. If this has an issue, all the subsequent steps become problematic too, and claims get denied quickly and ruthlessly.

When did you last check the effectiveness of your eligibility verification process? Surveys state that the rate of denials due to ineligibility ranged between 1% and 50% in the healthcare industry.

Quintessence is backed by 100s of years of combined industry experience, and our AI and ML-based tools back our teams up and help improve your overall RCM operations, including tightening and fine-tuning your patient eligibility verification process.

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