How to Choose the Right Patient Eligibility Verification Processes for Your Practice

If you thought that medical coding and billing used to be a complicated process, it’s likely only become more complicated since the recent transition to ICD-10. In addition to this change, the recent growth in the number of high-deductible and cost-sharing insurance plans, as well as the Affordable Care Act, have likely also had some sort of effect on your revenue cycle.

The solution to managing all of these recent changes? Patient eligibility verification.

Patient eligibility verification is the process of contacting payers (insurance providers, Medicare, etc.) to determine the current standing of a patient, in terms of their coverage, their remaining deductible, and any copays they should be expected to pay.

The benefit of this? Well, your practice will reduce the number of reimbursement claims that are denied because of insurance issues, which will subsequently get you your money quicker and reduce your A/R days outstanding. Eligibility verification systems also enable your staff to have easier communication with patients about their payment responsibility, resulting in happier patients.

Ways to Verify Patient Eligibility

Over the years, a number of methods have been developed for verifying patient eligibility, and finding the right method for your practice is essential to effectively running your practice.

Old School Methods

Traditionally, patient eligibility was typically conducted one at a time, on a rather irregular basis, as patients used to stay with their insurance providers for longer periods of time. This involves calling or faxing individual payers regarding individual patients, which tends to be a rater time-consuming task for practices, taking time away from caring for patients. Though most practices prefer to verify patient eligibility more frequently, some practices still utilize these processes.

Carrier Portals

Carrier portals, or payer portals, are another option, and eliminate the time your staff might spend on hold using the old school methods. However, because carrier portals are hosted by bigger payers on their websites, your staff must go to each individual website to verify eligibility, one patient at a time. Different carrier portals also require different types of information.

Clearinghouse Systems

Clearinghouse systems, however, eliminate the need to go to multiple different carrier websites to verify eligibility. Clearinghouse systems are also web-based, and offer the ability to verify batches of patients at a time—so long as the clearinghouse systems have connections with the right payers. Though these solutions will take time to set up, they require less day-to-day man hours to operate.

PMS Integrated Solutions

Additionally, some of these clearinghouse systems can be integrated with your practice management software (PMS), enabling you to verify patient eligibility without stepping out of your workflow. However, not all clearinghouse system providers offer this, nor do all practice management software providers, so it’s smart to double-check with both providers.


The above 4 options to verify patient eligibility are all in-house methods, though an increasing number of practices are electing to outsource their verification needs. This is often a viable option for many practices because it takes all of the responsibility for checking patient eligibility (and often the responsibility for securing payments, as well) and delegates the tasks to a vendor that specializes in them, cutting down on time between payments and claim denials.

Choose the Right Patient Eligibility Verification Processes for Your Practice

Of course, every practice is different and has different needs. Some practices may still be most comfortable with the old school methods of calling and faxing in patient information, while some may need an upgrade. It’s more important to find the right fit for your practice than it is to get the most updated technology.

Amongst others, there are a number of questions below to ask yourself before deciding on new verification processes for your practice:

  • How many patients do you see everyday? Every week? Month?
  • How frequently do you run patient eligibility verification requests?
  • How many of you claims get denied because of insurance issues?
  • How do you currently run patient eligibility verification requests?
  • Do you have enough staff to call or fax in each request?
  • Is your staff comfortable with using web-based portals or clearinghouses?
  • Is your staff technically savvy and able to adapt to new systems or changes in current systems?
  • Do you have enough staff to keep up with regular patient eligibility verification, or do you need help?

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CASE STUDY: Maximizing Revenue

CASE STUDY: Maximizing Revenue

Leveraging pVerify tailored insurance verification, eligibility solutions, and support, a healthcare customer with close to 200 locations significantly reduced bad debt, resulting in a client-estimated $3.9 million in saved revenue

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