How medical insurance verification software can help healthcare organizations

Published: March 25, 2024 by Experian Health


Discovering that a patient’s insurance doesn’t cover planned care is frustrating for patients and providers. With revenue and patient satisfaction on the line, verifying active coverage should be simple and efficient. However, the process often involves digging through an ever-expanding mountain of data, which consumes valuable time and resources. Increasing patient volumes, frequent payer updates, and new demands for pre-authorization all play a role. Additionally, the impact of nearly 12 million Americans losing Medicaid coverage since April 2023 adds to the challenge.  It’s unsurprising that many healthcare organizations no longer rely on manual processes to verify a patient’s insurance details. To address these issues, many providers are turning to medical insurance verification software.

The CAQH 2022 Index reports that automation of eligibility and benefits verification has increased by 25% over the last 10 years, as providers turn to medical insurance eligibility verification software for more reliable results. This article looks at how these tools are helping healthcare organizations increase their profitability and the questions to consider when selecting the right eligibility verification solution.

What is medical insurance verification software?

Medical insurance verification software automates the process of checking that a patient’s insurance information is current and correct. With just a few clicks (or just a single click when using Patient Access Curator), the software collects data from multiple sources to confirm that prescribed services or treatment are covered by the patient’s health plan. Unlike manual processes that involve checking individual payer websites and cross-referencing patient data by hand, an automated solution returns accurate information in an instant.

Adoption of this software has grown significantly in recent years because of its ability to drive operational efficiency and reduce revenue loss. More than 90% of medical providers now opt for electronic eligibility verification, according to the CAQH 2022 Index. The report highlights this as a top savings opportunity for the industry, having helped providers avoid almost $81m in costs arising from manual transactions. It’s particularly cost-effective for smaller organizations with tighter budgets.

How it works: the eligibility workflow

Here’s what the insurance eligibility verification process looks like in practice:

  1. As soon as the user registers the patient, they can make an eligibility request and the software immediately determines whether the patient has coverage on file and whether that coverage has been verified.
  2. An optional MBI lookup service can be used to check transactions against MBI databases to see if the patient may be eligible for Medicare.
  3. If a patient is eligible for Medicare, the response will confirm the type of Medicare and flag up any missing patient information. If they are not eligible, the transaction will be routed through the regular verification process.
  4. For non-Medicare transactions, the software will confirm any other coverage found and provide subscriber details.

Benefits of medical insurance eligibility verification software for providers and patients

As with all data-driven revenue cycle processes, even the smallest eligibility verification errors can result in denied claims, wasted staff time and lost dollars. Automating the process minimizes the risk of incomplete patient data, outdated insurance information and simple human mistakes. But while accuracy is paramount, the benefits of insurance eligibility software go much further:

  • Boost cash flow and cost savings: Identifying the correct insurance coverage improves the billing process to increase and accelerate reimbursement. With fewer denied claims, more revenue comes in the door and staff time need not be spent on costly rework.
  • Increase operational efficiency: Software automates and streamlines the verification process, saving time and reducing the burden on staff. As labor shortages persist, fewer staff may be available, so any action that makes better use of resources will result in efficiency gains and let staff focus on higher-value tasks.
  • Simplify workflows: Busy providers don’t have time for lengthy onboarding exercises or training programs. An eligibility verification product with an intuitive interface that integrates with other information management systems can shortcut the learning curve, while alerts and smart work queues help staff prioritize the right tasks.
  • Leave room to grow: Providers need solutions that can scale in step with increasing patient numbers and administrative complexity. Medical insurance eligibility verification software can adapt to changing needs with minimal disruption.
  • Improve the patient experience: A more reliable verification process means providers can generate accurate and timely cost estimates for patients, which makes it easier for them to understand their financial responsibility and plan for bills. And by eliminating time-consuming manual tasks, software speeds up registration and gives staff more time to focus on patient care. Again, this means more dollars coming in the door.

Key features to look for in medical insurance verification software

When selecting a platform, healthcare organizations should consider the following questions:

  • Does it pull from reliable data sources?
  • Does the software integrate with existing payer and information management systems?
  • Is the system easy for staff to use?
  • Does it incorporate monitoring and reporting functions?
  • Does the supplier offer ongoing support?

Experian Health’s Insurance Eligibility Verification solution was developed with these questions in mind. It gathers data from more than 900 payer websites, along with other sources, to generate detailed responses. Advanced search optimization increases the chance of a positive match, so no active coverage slips through the net, while the CAQH COB Smart® Data feature enhances coordination of benefits information for accurate, real-time responses. Providers that already use Experian Health products, such as eCare NEXT®, can access Eligibility through the same interface, so staff can use it right away and generate combined performance reports. One of the major advantages of Eligibility is the optional Medicare beneficiary identifier (MBI) look-up service, as described below.

And now, healthcare providers have an additional tool to add to their eligibility arsenal: Patient Access Curator. With Experian Health’s recent acquisition of Wave HDC, users can leverage AI-guided data capture technology to quickly check and correct patient insurance information. Patient Access Curator not only verifies insurance eligibility, but it also facilitates accelerated coordination of benefits processing, runs automated MBI checks, searches for missing coverage, and analyzes a patient’s propensity to pay – all in a single click.

Close the coverage gap with medical insurance verification software

While insurance verification software improves eligibility review processes, one question remains: how can providers help patients who are found to have invalid coverage? One option is to help patients find alternative coverage, using a solution like Coverage Discovery. Similarly, Patient Financial Clearance can identify patients that may be eligible for Medicaid or charity assistance, and can point them toward manageable payment plans if they have a self-pay balance. In this way, automated solutions can go even further to help providers create a positive patient experience and ultimately reduce the burden of bad debt.

As providers embrace the benefits of automation, selecting the right solution is crucial. Tools that integrate workflows throughout patient access and the wider revenue cycle will make it easier to manage change, maximize resources and boost profitability.

Find out more about how Insurance Eligibility Verification helps healthcare organizations increase reimbursements with automated eligibility checks.

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