Eligibility Verification
Real-time eligibility and benefits verification before the visit — eliminating denials at the source instead of fighting them after.
Why it matters
The hidden cost of getting this wrong
Roughly 6% of claims get denied for eligibility issues — wrong member ID, terminated coverage, missing prior auth, out-of-network plan. Almost all of those are preventable with a 90-second eligibility check before the visit. Most practices either skip eligibility entirely or only do it for new patients. We verify every single appointment, every day, before the patient arrives.
What's included
Everything in this service
Real-time eligibility checks via 270/271 EDI for every appointment
Prior authorization tracking (initiation, status follow-up, expiration alerts)
Coverage termination flagging before the visit
Specialist referral verification when required
Out-of-network status flagging (with patient communication script)
Deductible, copay, and coinsurance estimates for patient cost transparency
Daily exception report for visits that need front-desk action
Common pitfalls
What we see go wrong elsewhere
Patterns we run into when we audit incoming practices. If any of these sound familiar, your current setup may be leaving money on the table.
Only verifying new patients — established patients change plans constantly (especially around January)
Verifying once a year instead of every visit — coverage changes mid-year more often than people think
Skipping prior auth checks because 'the front desk will catch it' — they usually don't
Not flagging out-of-network until the claim denies, leaving the patient with a surprise balance
Verification done same-day morning-of, leaving no time to fix issues before the patient arrives
Performance benchmarks
What we hold ourselves to
Industry medians shown where applicable. We track these every week and report them to you, in writing.
<1%
Eligibility-related denial rate
100%
Pre-visit verification rate
5+ days
Prior auth initiation lead time
Frequently asked
What practices ask before they switch
Won't this slow down our front desk?+
No — we run eligibility 24-48 hours before the visit and flag exceptions to your front desk in a daily report. They only deal with the few that need attention. Your front desk doesn't run individual checks unless something flags.
What about same-day add-ons or walk-ins?+
Real-time eligibility check at check-in, results in under 30 seconds for most payers. The handful where the EDI response is delayed get a flag for the biller to follow up that afternoon.
Do you handle prior auth requests, or just track them?+
Both. We initiate prior auths for procedures, imaging, DME, and specialty medications. We track every open auth through approval, denial, or peer-to-peer escalation.
Want to know what eligibility verification is costing you?
Get a free Revenue Leakage Analysis — a one-page report with three specific revenue leaks at your practice and what they're costing per year. Delivered in 3 business days. No sales pitch.