Mastering Patient Eligibility Verification: Best Practices, Proven Solutions and Real-World Examples 

[SSI Preventing Eligibility Denials Series: Part 3 of 3]

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April 6, 2023

If you’ve already read our blogs on Understanding Eligibility Denials and The State of Eligibility Verification in Hospitals and Health Systems, the need for an effective eligibility verification process and solution is clear. For the last blog in this series, we are going to cover the best practices for eligibility verification, a real world-case study, and solutions to address eligibility needs.


Best Practices for Preventing Eligibility-Related Denials

As an increasing number of consumers adopt high-deductible health plans and frequently switch insurance plans, it is imperative for healthcare organizations to verify patient eligibility early and often to stay ahead of any potential changes.

Top Tip: Check eligibility early and check often. The continuous assessment of eligibility sometimes allows for retrospective coverage, meaning it can be applied to previously rendered services.

A review of SSI claims data across the US still shows work to be done to prevent and manage denials related to eligibility. According to a 2018 report by Sage Growth Partners of hospital C-suite and finance leaders, 18% reported they did not recheck patient eligibility.

As the workforce continues to turn over at unprecedented rates, it’s critical to routinely review training and processes to ensure staff understands how and when to carry out eligibility verification processes.

Further, by incorporating the right eligibility verification solutions into your workflow, you can avoid denials and keep your revenue flowing.

Best practices are to confirm eligibility:

  • When scheduling appointments
  • Before appointments
  • At check-in
  • After appointment
  • On regular cadence for some patients/payers
  • Before claim submission


SSI Eligibility eBook cover

The Definitive Guide to Preventing Eligibility Denials

This comprehensive guide from SSI is a must-read for hospitals and health systems looking to improve their eligibility verification process and reduce claim denials related to eligibility issues. It covers the claim denial problem, the state of eligibility solutions in healthcare, and the importance of eligibility verification in denial prevention strategies. Discover best practices for effective eligibility verification and real-world examples, as well as how technology can streamline the process.

Provide your email to get the eBook.

Real-World Example: Denial Prevention with a Focus on Eligibility

As Anderson Regional Health System, a two-hospital system in eastern Mississippi, was preparing for price transparency compliance in 2020, they felt there was an opportunity to truly integrate eligibility along with estimation and collections. Having been a longtime partner of SSI for claim submission and clearinghouse solutions, Anderson Regional approached SSI about integrating Access Director, SSI’s suite of access management tools, into its existing revenue cycle management platform to create a fully custom package that would check for patient eligibility at all the right times, among several other denial reduction strategies. With its denial budget decreasing every year, Anderson Regional wanted to do everything possible to address denials and meet its revenue goals.

The hospital system decided to move forward with the new strategy and worked with SSI in the fall of 2020 to implement Access Director’s full suite of patient access functionality.

Fast-forward to the present day, Anderson Regional now has a single solution to manage front-end verification for eligibility, estimation, collections, back-end claims scrubber, clearinghouse, and denials. This is integrated with their host EHR, which facilitates the movement of data to quickly identify areas for improvement.

Some of the results Anderson Regional has achieved, which occurred despite the loss of 28% of the patient access workforce during the pandemic, includes:

  • Over 109,000 alerts over a 12-month period for patients that identified having Medicare coverage but where eligibility response indicated other insurance coverage that was tied to Medicare Advantage. These alerts were able to get corrected on the front end, saving the team time and avoiding rejections or possible denials.
  • Pre-billing eligibility edits caught 1,803 edits worth $5.9 million.
  • 63% reduction in COB denials over a 12-month period over the prior year period
  • 21% reduction in Medicare COB denials

The results are a testament to the patient access team as well as all the denial processes and tools the hospital has implemented.



About SSI Eligibility and our Approach

The shortage of expert revenue cycle team members and more consumers frequently switching insurance plans has led to a perfect storm for potential eligibility verification errors that can result in higher denial risk and negatively impact reimbursement. That’s where SSI comes in.

SSI Eligibility helps prevent unnecessary denials from the start by allowing providers to easily confirm correct insurance and benefits coverage, including all payers. Using SSI Eligibility, organizations can verify eligibility for every patient, every time, within seconds – and improve cash flow as a result.

Additionally, SSI Eligibility helps providers follow best practices of checking eligibility early and often throughout the revenue cycle. Included in SSI’s robust edits library, the Pre-Billing Eligibility edits (PBE) act as a safety net, allowing providers to catch potential denials on the back end before submission to payers.

SSI believes in a human-led, technology-supported approach to managing the toughest RCM challenges, including eligibility. In addition to our eligibility verification solution, we offer the following complementary solutions to help create a smoother and more streamlined approach to denial prevention.

  • Real-time eligibility that seamlessly integrates with your HIS system
  • Exception-based workflow featuring intelligent alerts and actionable guidance
  • Comprehensive direct connections to a vast number of local, regional, state, and federal payers
  • Easily check eligibility across the revenue cycle per best practices
  • 270/271 Eligibility and Benefits Inquiry and Response using an industry-standard X12 interface
  • Identify unknown Medicaid and commercial insurance coverage for self-pay patients
  • Automatically identify retroactive insurance coverage

Talk with a specialist today about your current eligibility verification process and learn how SSI can help reduce claim denials and maximize reimbursements for your hospital or health system. Want to take a more in-depth look at the overarching claim denial problem? Download our new eBook, The Definitive Guide to Denial Prevention. It provides a foundational overview of the claim denial problem, real-world results of eligibility verification implementations, and proven eligibility verification solutions.

Download our new eBook, The Definitive Guide to Medical Claim Denial Prevention, to read more about the claim denial problem, real-world results of eligibility verification, and proven eligibility verification solutions.