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Why is Eligibility & Benefits Verification an essential part of RCM?

Today’s healthcare scenario has become so complex and constantly changing that many patients don’t know what coverage their healthcare insurance agents provide and which hospitals or doctors fall in-network. Eligibility & benefits verification is a way service providers can assess the coverage situation of patients and minimize the risk of denied payments after services are rendered.

What exactly is eligibility & benefits verification?

As the name suggests, this service is part of Revenue Cycle Management operations that checks insurance coverage eligibility and accepts patient benefits before rendering needed service. 

Every insurance policy comes with closely defined terms and conditions. Depending on the patient’s premium, they may be eligible for reimbursements for only certain types of healthcare treatments. Even if the patients are unaware of these exact details, the healthcare provider must check eligibility and benefits and make the right decisions.

Eligibility & benefits verification is crucial because, according to experts, 75% of claims are rejected because of ineligibility issues. When a claim is rejected or denied because the patient is ineligible for coverage, then there is no way you can get the bill reimbursed, and this money needs to be written off.

When a considerable portion of the bills you submit get rejected due to ineligibility, you start losing revenues after rendering services, after spending time and money from your end. 

This is something no healthcare practice can afford to keep doing over time.

Three basic details must be checked before the patient enters the clinic or practice.

  1. Coverage status
  2.  Eligibility status
  3. Active or inactive status

Once these details are checked, you can get a grip on how much the patient’s responsibility towards the final bill could be and let them know. This will help patients come prepared.

Checking these details will also give your billing team an idea of how simple or time-consuming that particular claim will be. Eligibility & benefits verification can help your billers plan their tasks well in advance and stay prepared for challenges. 

Patients are always in a hurry to get discharged or leave the clinic after treatment. Without eligibility & benefits verification, some of the claims may get stuck mid-way, needing further information or with a partial payment. This can lead to two things.

  • A delay in discharge processes
  • The patient presented with a large part of the bill that the insurance did not cover.

Patients get taken aback by both these discomforts, and when you verify their coverage details in advance, this shock can be prevented.

As a healthcare provider, you are doing the right thing by performing eligibility & benefits verification in advance and letting your patient know if their coverage extends to the chosen medical practitioner. 

This is morally and ethically the right thing to do and will improve the patient experience. 

How can Quintessence help?

Quintessence offers end-to-end eligibility & benefits verification processing for all clients. We check all necessary details, including the following, that will affect payments.

  • Coverage validity
  • Primary and secondary payer details
  • Allowed benefits
  • Co-insurance and deductibles

Some claims may require prior authorization, and if that is missed, then getting reimbursements becomes a challenge. Our intelligent tools are equipped to identify such cases in advance and ensure prior authorization is done so that clean claims can be sent for reimbursements. 

QuintAna is a specialty automation tool that we have designed to identify prior authorization requests in seconds. This tool can reduce the need for constant manual intervention and increase accuracy and speed when it comes to prior eligibility & benefits verification.

This tool can be integrated with most PMs and can be tweaked to exactly match your requirements. This BOT can also automatically download rejection reports from the clearing house and take relevant action. 


Eligibility & benefits verification is a small yet significant part of your RCM operations, and getting this right helps build the right platform for the rest of the steps. Quintessence is backed by intelligent tools and an expert billing and coding team that can automate eligibility verification and prevent denials stating ineligibility. 

Explore your current front-end processes and see how effectively and consistently your team takes up eligibility & benefits verification. Sometimes, your team maybe equipped but lack time to do this thoroughly. In that case, automation tools like QuintAna may help.

Do get in touch with experts at Quintessence to know more about this. 

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