Eligibility and benefits verification
Eligibility denials are the most preventable denials there are. We check coverage before the patient arrives, not after the claim comes back.
The problem this fixes
Coverage changes constantly — plans terminate, employers switch carriers, deductibles reset in January, and patients don't always know. When eligibility isn't verified before the encounter, the practice finds out weeks later via a denial, by which point the patient is gone and the balance is hard to collect.
There is a second cost beyond the denial itself. When coverage is not verified, the front desk does not know what to collect, so nothing is collected at the point of service. The balance becomes patient responsibility discovered weeks later, and patient balances collect substantially worse than insurance balances — particularly large ones, and particularly from patients who believed they were covered.
What goes wrong when this is done badly
Four failure modes we see repeatedly, and each one is a process problem rather than an effort problem.
Checking coverage but not benefits
An active plan is not the same as a covered service. Visit caps, exclusions, unmet deductibles and carve-out administrators all sit behind an eligibility response that says "active".
Verifying the practice, not the provider
Network status is specific to the rendering provider and the location. A new hire whose enrolment is still pending is out of network for that patient, whatever the practice's status.
Skipping same-day add-ons
Walk-ins and add-ons are exactly the appointments where coverage is least likely to be current, and exactly the ones a scheduled verification run misses.
January
Deductibles reset, employers switch carriers, and plans terminate at year end. A verification routine that works in June and is skipped in January produces a first-quarter denial spike every year.
What's included
Every item below is a deliverable, not a capability statement.
Active coverage confirmation
Before every scheduled visit.
Deductible status
Met, remaining, and reset date.
Copay and coinsurance amounts
By service type, not just a plan-level figure.
Out-of-pocket maximum tracking
So the front desk knows what to collect.
Plan limitations, exclusions, and visit caps
Checked against the service being provided.
In-network vs. out-of-network status
For the specific provider, not just the practice.
Prior authorisation requirement flagging
Raised before the appointment, not after.
Coordination of benefits
Identifying primary vs. secondary payer.
Referral requirement checks
Where the plan requires one.
Same-day verification
For add-on and walk-in appointments.
How it works
- 1 Schedule sync We read the upcoming schedule from your system.
- 2 Verification Coverage checked [CLIENT INPUT — typically 48–72 hours] before the appointment.
- 3 Exception handling Terminated or changed coverage is flagged to the front desk while there is still time to act.
- 4 Attachment A verification summary is attached to the appointment in your system.
- 5 Same-day cover Walk-ins and add-ons verified on the day.
What we check, and what it prevents
| Checked before the visit | Denial it prevents | Who needs to know |
|---|---|---|
| Active coverage on the date of service | CO-27 — expenses incurred after coverage terminated | Front desk, before the patient arrives |
| Primary versus secondary payer | CO-22 — coordination of benefits | Billing, so the primary is billed first |
| Deductible status and remaining balance | Patient balance discovered weeks later | Front desk, for point-of-service collection |
| Copay and coinsurance by service type | Under-collection at the desk | Front desk |
| In-network status for the rendering provider | CO-B7 and out-of-network processing | Scheduling, before the appointment is confirmed |
| Authorisation requirement for the planned service | CO-197 — no authorisation on file | Whoever obtains the authorisation |
| Referral requirement under the plan | Denial for missing referral | Scheduling |
| Visit caps and plan exclusions | CO-96 — non-covered service | Provider and patient, before the service |
What you get back
- A verification summary attached to each appointment before the visit
- A daily exception list of coverage problems that need a decision
- Prior authorisation requirements flagged in advance
- What the front desk should collect at the desk, per patient
Who this is for
- Practices with recurring CO-27 and CO-31 denials
- High-volume practices where the front desk cannot call every payer
- Practices with a heavy commercial or exchange payer mix
- Practices collecting little at the point of service
What we measure
The numbers this service actually moves. You see all of them weekly, in your own system, with the benchmark alongside.
-
Verification coverage The share of scheduled appointments verified before the visit, including same-day add-ons. Anything unverified is a coverage denial waiting to happen.
-
Eligibility denial rate CO-27 and CO-31 denials as a share of claims. These are the most preventable denials there are, and the rate should fall within the first month.
-
Exceptions raised before the visit Terminated plans, changed carriers, exhausted benefits and unmet deductibles surfaced while the front desk can still act on them.
-
Expected patient responsibility per visit What the front desk should collect at the desk, per patient. Money collected here does not become a statement, a phone call and an ageing balance.
Benchmark ranges are sourced from MGMA and HFMA MAP Keys. MedBil's own figures are published only with a stated measurement window, per specification section 12.7.
Where this matters most
The specialties where this part of the cycle carries the most risk and the most recoverable revenue.
Start with your own numbers
We measure your denial rate, A/R ageing and net collection rate against industry benchmarks before you commit to anything. You keep the analysis either way.
- 90 days of claims data, no patient identifiers needed
- A written analysis, not a sales deck
- No contract, and no obligation to proceed
- Client results published with a stated measurement window, once available
Questions about eligibility & benefits verification
How far in advance do you verify?
[CLIENT INPUT — typically 48–72 hours before the appointment]
Can you handle same-day add-ons?
Yes.
Does this include prior authorisation?
Verification flags when auth is required. Obtaining it is covered under our prior authorisation service.
Related
Where this connects to the rest of the cycle.
Accounts Receivable Recovery
We work aged and legacy receivables other billers gave up on.
See A/R recoveryPrior Authorization Services
Auth requests submitted, tracked, and escalated so procedures aren't delayed.
See prior authorizationMedical Billing & Coding Audits
Retrospective and pre-bill audits that find both compliance risk and missed revenue.
See billing & coding audits