Importance of Eligilibility in Denial Management

Oct 20, 2020

Every denial received on a claim billed to payer, essentially is a revenue leak. Denials can be appealed and appeals prove to be very costly for providers. One of the predominant amongst denials that stands out is the Eligibility denial.

Few simple steps and precautions can save you a lot if we can just fix this one denial. The very first step to begin with is the eligibility check in itself.

At Clarus the team has the knowledge on the leading causes of Denials and works through these most efficiently to prevent the revenue leaks even before they occur. Pertaining to the Eligibility  we conduct the checks at a very granular level where we:

Obtain Complete and Accurate Demo Graphics Information

  • Obtain the complete Insurance information

  • Obtain the COB information pertaining to the insurance

  • Verify the applicable Insurance Benefits

  • Ensure the policy is in Active reimbursable status.

  • Identify the Uninsured individuals at the time of Scheduling

  • Obtain information of the Guarantor for Financials

  • Determine the Patient's estimated responsibility. 

With the above said and done, the providers achieve : 

  • Zero Denials pertaining to Eligibility

  • Positive patient reviews

  • Estimated amount of patient dues

  • Improves Point of Service Collections

  • Reduction in financial risk

  • Reduces Patient wait times and paperwork pertaining to Demographics and Eligibility

The above approach at Clarus helps the providers eliminate many interlinked Denials with Eligibility such as

  • Benefits Maxed out

  • Services not Covered per patient plan

  • COB not on file/ Not Updated

  • ABN is not on file for Medicare Beneficiaries

  • Demographic information related Rejections

  • Authorization Criteria not met

And if the above are getting tackled, don’t you think you will see an reduction in your denial rate?

Phani Ram