Automating EDI Batch Eligibility

Is This Patient Covered

Making EDI Batch Eligibility Easier

Automating benefit eligibility requests is crucial to reducing risks for healthcare providers. Rising healthcare costs, an increase in plan options and expanded Medicaid eligibility have created a landscape of confusion and financial risk for many healthcare providers. Without an easy, fast and accurate way to routinely check patients’ coverages and changes, any provider is in for potential cash flow issues from delays and denials. Not to mention from hours of time wasted with additional patient and payor interactions.

Here are two very real scenarios most any provider can relate to.

  • Patient A has changed coverage from her last visit, but never informed you or your staff. She arrives for her appointment in a hurry, and signs in. The conversation begins, with an already busy waiting room, and busy providers. By the time things get figured out, everyone in the room is in for a longer wait, stress and dissatisfaction. And everyone behind the scenes is in for extra time spent on eligibility verifications after the fact.
  • Patient B is served by a home health provider. His case manager or visiting nurse drives client to client, and arrives at the home. Services are delivered as usual. But when the day is done, the billing staff learns that the patient had switched HMOs, and the new plan does not cover the services already rendered. Or that he has stayed with the same insurance, but is on a different plan not covering the visit.

So what are the options?

  • Insurer-Provided Portals

Most insurance providers, including Medicare and Medicaid, have developed web portals and user interfaces for individual patient eligibility requests. These often free solutions are ideal if you have small volumes of patient activity. They require manual entry by your staff, and sometimes multiple interfaces. It wouldn’t be unusual for an organization with a large Medicaid population to allocate 8-10 extra hours each week to check eligibility statuses. Due to the manual burden, there could be a lack of frequency for manual checking opening up the possibility for missing eligibility changes. So be careful and create a plan in advance to allow enough time to close as many potential gaps as possible.

  • Clearinghouses

Clearinghouses can offer you more efficiency—provided you are okay handing over control of your data and timelines. If this is an option for you, ensure you thoroughly research reputable companies in advance, evaluate the costs, efficiency and processes to find the right solution.

  • EMR or CRM Systems

Many electronic medical record and CRM systems now have the ability to create 270s or receive 271 transaction sets. Behind the scenes, the system is likely tapping into its own clearinghouses, and compiling the data for you. Review options and costs with your existing vendor.

  • EDI Middleware Software

One of the best solutions, no matter the size of your organization, is finding a software solution to do the work for you, while keeping it all in-house. While I admit my personal bias to this option as a middleware provider, it makes sense any way you look at it. EDI middleware offers you a low overhead cost and ease of implementation. Middleware software acts as an independent tool for use with data retrieved from your main EMR software. And it does not require implementation with your billing software provider. With intuitive middleware solutions like the EDI 270 Power Generator, you regain control and efficiency. You can access benefit eligibility in bulk before the time of service, letting your frontline staff rest assured a patient’s health plan covers the patient and service to be rendered. In many, if not most, cases you can also review dates for months in the past, as well as into the future (depending on your payer’s guidelines). And you’ll avoid delays and higher costs of clearinghouses, which often charge you claim by claim by claim. Best of all, you’ll have a more streamlined waiting room, more efficient scheduling, an improved patient experience and staff satisfaction. That all adds up to profitability ensuring your organization and team will be here to grow and expand for the long haul.