Improve eligibility and estimates with a better payer intelligence engine


Improve eligibility and estimates with a better payer intelligence engine

Every year, approximately 45% of Americans consider changing their level of coverage, which has a cascading effect on their benefits, in- and out-of-network options, and transparency of their financial accountability to patients.

All of these changes expose healthcare providers to potential initial errors that can ultimately lead to a higher risk of refusal or non-payment by patients. Plus, with employees changing jobs at a record pace and moving in and out of exchanges, it’s easy to see why accurate eligibility verification remains elusive for many vendors.

In addition to patients switching plans, payers continually update membership lists and benefit databases. Payers have moved much of the member experience and relevant benefit information to online payer portals, forcing providers to rely on disjointed information sources and outdated EDI solutions. Additionally, each payer approaches this differently despite established standards-based bodies like the CAQH.

Today, it’s not just about whether a patient is covered. Eligibility is based on specific benefit levels (i.e., copays, coinsurance), in- and out-of-network determination, authorization, and deductible/out-of-pocket information for a specific episode of care . It’s no surprise that front-line staff sometimes get things wrong.

What’s inside:

  • Why eligibility is no longer a commodity and what providers need to have to ensure eligibility is accurate

  • A real example of payer analysis

  • How Suppliers Use Purpose-Built Automation to Do Less Manual Work and Achieve More (and Better) Benefit Rule Coverage, and therefore Estimation Accuracy

  • Supplier use case examples with results

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