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Case study: How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks

Published: June 3, 2024 by Experian Health

Case-study-How-Providence-Health-found-30M-in-coverage-and-reduced-denial-rates-with-automated-eligibility-checks

“We are really happy with Experian. It takes away duplication of efforts and allows us to see the bigger picture. The eligibility solution works well for our team and patients.”

—Emily Brown, Director of Operation Excellence at Providence Health

Challenge

Providence Health is a leading health system comprising of 56 hospitals and over 1,000 physician clinics. With an annual patient volume of over 28 million, Providence strives to prioritize the well-being of their patients by providing convenient, accessible, and affordable medical services.

Because of high patient volumes, they faced issues with slow payer eligibility processes and increased eligibility denials, which meant their staff spent a lot of valuable time verifying eligibility manually.

Additionally, as Epic’s payer plan table expanded, Providence Health needed an efficient way to consolidate and align the data pertaining to insurance plans, contracts, and reimbursement details. In order to streamline the process and keep their staff within the system, Providence Health sought to automate eligibility tracking.

Solution

Providence Health implemented Eligibility Verification and leveraged the Bad Plan Code Detection tool, which identifies coding errors before they’re submitted to payers. With this solution, the system immediately alerts users when an incorrect plan code is flagged, allowing users to fix any issues quickly and avoid costly claim rework. Additionally, integration with Epic facilitated seamless 1:1 plan mapping, and automated the creation of new coverage records in Epic based on responses received. This streamlined the process, eliminating guesswork for staff and ensuring accurate plan selection.

Emily Brown, Director of Operation Excellence says, “Our search for a solution that seamlessly integrates with Epic led us to choose Experian Health as our preferred vendor, given their proven track record of working with Epic.”

By working with Experian Health, Providence has uninterrupted service and connections to over 900 payers, with backup connectivity to 300 additional payers. Providence staff can utilize automated work queues fueled by response data and custom alerts, which allows them to work more efficiently.

Outcome

Thanks to Eligibility Verification, Providence Health achieved the following results:

  • Found an average of $30 million in coverage annually
  • Saved $18 million due to decreased denial rates within five months

By automating eligibility checks for high patient volumes, Providence Health boosted patient satisfaction while significantly reducing staff workload. Partnering with Experian Health allowed them to identify an increased amount of active eligibility, ensuring accurate reimbursement and avoiding claim denials. Automation also eliminated time-consuming tasks, allowing staff to focus on providing better patient care.

“Checking if my insurance was accepted was a fast and friendly process. The staff even helped clarify which insurance was the right one for me since I had multiple cards.”

– Providence Health Patient

Learn more about how Eligibility Verification helps healthcare organizations access real-time insurance coverage data, improve reimbursement rates and avoid claim denials.

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