Agents of a leading U.S. revenue cycle management (RCM) service provider were manually logging into healthcare provider portals to check patients’ eligibility and benefits for upcoming appointments. Accurate confirmation streamlines claim submissions and health plan reimbursements. However, with more than 120 provider portals changing every quarter and agents expected to be familiar with each of them, the verification process was complex.
The provider’s existing eligibility and benefits confirmation process involved more than 250 complex business rules. Data had to be extracted from more than 35 fields pertaining to co-pays, co-insurance, annual deductibles and remaining deductible amounts. For appointments made on short notice, these tasks had to be completed within a day. This tedious, time-consuming process was prone to errors. It also risked patients receiving incorrect information and providers submitting inaccurate claims that eventually would be denied.