Why Checking Patient Eligibility Is Such A Big Deal

By Nicole Fletcher,

The healthcare industry in the United States is large and complex to say the least. The costs associated with every piece of this expansive system are significant, accounting for a higher percentage of American GDP than the vast majority of other nations. Much of this cost is to due to system wide inefficiencies, which are traceable to legacy techniques and systems for information processing that are outdated and silo'd. The following post will discuss the eligibility piece of the puzzle, touching on why it's so unnecessarily complex - and what we can do to fix it.

Current Model

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Consumers, i.e. patients, don't often think about the nuts and bolts processes that take place once they hand their insurance card through the doctor's office window - but indeed, there are many. Once check-in takes place, the front office has no idea whether or not the card representing a patient's insurance plan is up to date, or even real. Eligibility checks are very important because if a patient is not eligible and the doctor sees or treats him or her anyway, without a self-pay form,  the doctor will likely lose the ability to receive payment from the claim.

Many assume there must be some real-time database that gives front office staff access to this information. In fact, until recently, there has been no such database. Instead of simply plugging a patient insurance policy number into a clean portal, the doctor's office staff has had to manually call the insurance carrier in question, wait on hold, talk to someone and confirm patient eligibility (more on that process here). As you can imagine, if an office staff is juggling even just a few patients at a time, all with different insurance carriers, this can be ridiculously time intensive and inevitably, these checks get put on the back-burner, at the expense of a quality patient experience.

In recent years, insurance company website portals have improved and with many of them, doctors' offices can now visit those websites to check patient eligibility. But that still requires visiting multiple carrier sites, locating their login information, navigating those interfaces and hoping they're up to date.

So, what if there were a way to bring this part of healthcare into the 21st century and minimize the lost soft and hard costs? And if there was, how much might it save?


The API Model Cost Advantage

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By using the API technology enjoyed by most other industries today (think finance, transit, etc.), medical providers can save in cost of overhead and the hard costs associated with not being paid for uncovered patients. Existing electronic verification (like insurance carrier websites) accounts for ~63% of the over 3 billion verification transactions yearly. The API model however, is 89% cheaper than that, not to mention a whopping 98.5% cheaper than manual verification, which still accounts for 37% of all transactions.


The Eligibility API

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Let's imagine for a moment that the existing 1.15 billion annual manual eligibility verifications were done via the API model. By saving $3.48 per transaction, ~$4 billion would be saved annually. Similarly, if the existing 2.59 billion annual electronic eligibility verifications were done via the API model, saving $.41 per transaction would save ~$1 billion annually, totaling $5 billion annually in total savings for providers - just in eligibility checks.


Our Eligibility Solutions

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Our X12 API is connected to more than 300 insurance carriers, which represent over 80% of covered lives. Developers and startups can easily access our platform to build their own eligibility product in just a few hours by using our clear, user friendly documentation. For physicians, practitioners and small practices, and for others with an immediate need to check patient eligibility without a development team, we built our Eligibility App. This simple, web-based design allows providers to check patient eligibility in real-time, saving frustration, time and money in both the short and long term.

We can no longer pontificate ways to 'fix' healthcare. We can though, improve efficiencies within it - and  we are certainly are eligible for that.  

The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: API, Dev, Providers


  Comments: 1

  1. Nicole, thanks for the great information. I am a consultant that works with chiropractors and am trying to get them and their staff to understand the importance of including eligibility in their normal workflow rather than something to do if and when they have time.

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