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Mastering Eligibility Verification - The Quintessence Way

Eligibility verification is a common practice that all healthcare brands use to reduce the risk of non-eligibility denials. One of the first things denial management service experts do when they take up a client is check their non-eligibility denials and create strategies to tackle them. Quintessence is one of India’s top healthcare RCM companies offering global clients end-to-end revenue cycle management services.

According to Transparency Data released by CMS in 2022, about 14% of all denials of in-network claims were for excluded services, and 8% were due to a lack of preauthorization approvals. In comparison, only 2% were based on medical necessity.

This means that while the medical experts struggle to make correct spur-of-moment decisions, the backend team is flailing behind, missing out on primary eligibility verification and preauthorization.

According to our denial management service experts, here are a few common eligibility denials to be aware of.

  • Member ineligible on detail date of service
  • Member partially ineligible on detail date of service
  • No coverage for the billed procedure
  • Member covered by a different insurance

There are three common ways a practice can check for eligibility coverage.

  1. Manual checking
  2. Electronic real-time checking
  3. Combination of both manual and electronic real-time checking

Quintessence believes in the power of harnessing technology, and that’s why we have the best practices for electronic real-time eligibility verification in place.

On the other hand, for cases where digital access to records isn’t possible, we have a dedicated calling team who will take up manual checking to complete the eligibility verification process on time.

This way, all your eligibility verification cases are attended on time and in the best way possible.

Dealing with eligibility verification – the Quintessence way

The way eligibility verification is done is mostly fixed. The main idea is to ensure you check a patient’s eligibility to receive certain services planned for and inform the patient in advance in case of non-eligibility issues.

So, what makes Quintessence different?

It has to do with how we approach the process first and how streamlined our operations are in the following steps. Everything that can be automated is done with the help of intelligent tools, and this also lowers the load on the denial management service team to a great extent. That’s an added benefit of getting things right at the foundation level.

Our Eligibility Verification Tool starts by getting the appointment schedule from the client’s PMS and begins by identifying which of these can go through successful electronic verification and which ones need to be manually verified.

The former category list is passed on to our super workers – the BOTs. Our BOTs are our superpower. They are harnessed with all the latest technical expertise and are deployed in almost all stages of RCM.

These BOTs perform multiple comprehensive checks and scans to generate the patient’s eligibility status. Cases that the BOTs couldn’t verify electronically were passed on to the manual checking team.

This seamless movement ensures no eligibility verification checks go unnoticed.

At every point, our BOTs keep updating the PMS, and the client can request a report to see the eligibility status report for the day at any point in time.

This is a great way to streamline eligibility verification quickly so you can ensure patients get to their appointments confidently, knowing they aren’t going to be bombarded with non-eligibility issues and surprise bills. This also helps your client send out claims without fretting about non-eligibility issues.

The denial management service team works hard handling everyday denials, and the revenue dips these causes. Managing eligibility verification right means them having to deal with one less thing, and that would bring down their overall load.

QuintAna: Our powerhouse for BOTs

Did you know we also have BOTs that handle prior authorization requests like a pro? Our BOTs can automatically capture charges, post payments, download records, and more.

All our BOTs are part of this wonderful technology we are proud of – QuintAna.

QuintAna is our exclusive custom-built suite of BOTs to target every single step of revenue cycle management. Think of these BOTs as a highly trained workforce who need no sleep or recovery and are better than the best minds in the industry. They can work 24/7, hasten payments, help claims move faster from end to end, and drastically improve patient trust and loyalty.

Benefits of letting the experts take over 

If you are a healthcare provider struggling to deal with eligibility verification or find your rate of eligibility-based denials much higher than the industry average, here are some benefits of letting an expert like Quintessence take over.

  1. Faster payments – denials increase the A/R time and bring down the practice’s cash flow and financial stability. We help hasten payments, so you are financially stable and growing.
  2. Decrease rate of denials – denials are strenuous to deal with and lead to resource expenditure. Focusing on perfect and comprehensive eligibility verification will help reduce the denials rate.
  3. Increase rate of claim approvals – when claims are approved on time, you get paid on time, and your patient gets much-needed closure and can move on. Ask our team the exact customized strategies to increase your claim approval rate.
  4. Improve patient experience – When you let experts handle eligibility verification, we ensure there are minimal chances of delays or blocks due to eligibility issues. This ensures your patients get treated on time and doesn’t put them into unnecessary financial commitments. All of this improves the patient experience.


Eligibility-based denials are one of the common preventable problems that denial management service teams face daily. Unfortunately, healthcare providers have to lose thousands of dollars each month because the backend team couldn’t verify patient eligibility on time.

If your eligibility denials are getting out of hand, it is time to bring in the experts to deal with them with an iron fist. Get in touch with our team to schedule a consultation on what to do to fix this quickly and permanently.

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