Running a medical practice is never just about seeing patients. There is a whole financial side that can get messy fast. One of the biggest headaches I have seen clinics face is medical billing denials. When claims get denied it can slow cash flow and frustrate staff and patients alike and most of these issues start with improper Eligibility & Authorization checks, which makes the entire billing process even harder to manage.
One of the simplest ways to prevent these denials is by performing thorough eligibility and authorization checks before the claim even leaves your office. These checks sound simple but they can save thousands in lost revenue. In this post I want to share what these checks are how they help reduce denials and a real case study showing the impact in practice.
What Are Eligibility & Authorization Checks
Let’s begin with the basics first. Eligibility & authorization both deal with a patient’s insurance coverage and whether there is a need for any service to be approved before being provided.
Eligibility checks confirm that the patient’s insurance is active covers the specific service and identifies any co-pay or deductible requirements. Authorization checks make sure that the payer has approved a procedure in advance if it is required. This is also known as the prior authorization process.
Without these checks a practice can submit claims that are incomplete or not approved. Insurers often deny these claims resulting in lost revenue and additional administrative work.
How They Reduce Denials
Think about it like this. If you know upfront that a patient’s coverage has lapsed or a service requires approval you can correct it before billing. That simple step greatly helps to reduce denials in medical billing and to achieve faster reimbursements.
Eligibility and authorization checks also optimize the healthcare revenue cycle through early error detection. This means your billing team spends less time chasing denied claims and more time focusing on accurate submissions.
For instance, insurance eligibility verification on the day of service helps your staff correctly collect co-pays. Moreover, obtaining prior authorization ensures that the payer has already approved the expensive procedure. Together, these checks minimize the risk of payment delays and claim denials.
How One Clinic Reduced Denials
I want to share a real storyline. A small orthopedic clinic in Ohio was struggling with high denial rates. Nearly 20 percent of their claims were coming back denied each month. Most denials were due to missing prior authorizations or inactive insurance coverage.
The clinic instituted a more organized eligibility and authorization checks workflow. Verification of insurance was performed at check-in by front desk staff, while the billing specialist confirmed prior approvals for every procedure before submission.
Results were noticeable almost immediately. Denials dropped from 20 percent to 5 percent in three months. Payments were received faster and staff spent far less time on claim rework. The clinic also started tracking metrics monthly to identify patterns.
They reported that their overall revenue increased by roughly 12 percent simply by catching issues before claims were submitted. And patients appreciated fewer billing headaches which improved satisfaction and trust.
This example shows how even small steps in verification can have a measurable impact on the medical billing process.
Best Practices for Effective Checks
To get the most out of eligibility and authorization checks there are some best practices to follow.
Verify insurance for every visit. Even returning patients may have switched plans or lost coverage. Confirm active insurance and plan benefits at check-in. Use technology for tracking. The results were not long in coming. In three months, the percentage of claims denied dropped from 20 percent to 5 percent. Payments were made faster, and staff spent less time on claim rework.
Train staff regularly. Staff should know how to check coverage, confirm prior authorizations and spot common mistakes.
Document everything. Keep notes of approvals and conversations with insurers. This documentation helps resolve disputes quickly.
Monitor trends. Look for patterns in denials to adjust workflows or catch systematic issues before they become a problem.
Adhering to the practices workflow will keep your claims clean and the revenue cycle flowing smoothly.
Common Mistakes to Avoid
Even when you do checks there are pitfalls. Here are common mistakes that still cause medical billing denials:
Assuming coverage is active. Insurance status can change mid-year. Always verify.
Not confirming prior authorizations. Even if a patient was approved previously new procedures often need separate approvals.
Incomplete documentation. Missing notes or forms can lead to denials even when eligibility is verified.
Delaying verification until after service. If you wait you risk denied claims and frustrated patients.
Ignoring payer-specific rules. Some insurers have unique requirements for forms or submission methods. Know the differences.
Avoiding these errors takes attention to detail but saves time and money.
Conclusion
Eligibility and authorization checks take just a few moments but can make a remarkable difference for practices they reduce denials, expedite payments and assist in the overall healthcare revenue cycle. The clinics that apply these checks will notice a reduction in rejection rates, which will ultimately make their administrative staff and patients happier!
If you notice your practice struggles with denied claims or late payments, consider implementing eligibility or even outsourcing the functions to a revenue cycle and medical billing company. Med Bridge LLC is an expert team that can efficiently handle your complete medical billing process. They are prepared to assist with eligibility checks and prior authorizations, so you can practice more efficiently without the payment delays.
The time is now to take action to protect your revenue and streamline your billing workflow. Implementing an eligibility check and authorization process in your practice is one of the easiest ways of getting paid on time, while avoiding unnecessary issues and headaches.
