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Patient eligibility is one of the most relevant criteria in communication with health insurers. Validating eligibility is essential to prevent billing denials and optimize patient routing, providing a more satisfactory clinical experience.
However, for this process to be efficient, healthcare institutions must have advanced resources and integrated solutions for communicating with insurers. Automation tools provide greater reliability to operational processes and enhance financial control by identifying factors that could lead to billing denials in advance.
Below, we explore how to optimize the procedure authorization process with health plans, the benefits of integrated solutions, and how to implement them in practice. Keep reading and start improving your staff's workflow and your patients' clinical experience today!
Why Validate Patient Eligibility with Health Insurers?
One of the most critical problems in laboratories, clinics, and hospitals is billing denials—payments that are not received or rejected due to discrepancies in the exchange of information with insurers.
Billing denials typically occur when the data provided by the institution does not match what is recorded by the insurer. This can happen for various reasons, such as incorrect completion of authorization forms, typographical or calculation errors (known as administrative denials), or disputes over a performed medical procedure (technical denials).
In this sense, validating patient eligibility with insurers is the first step in avoiding billing denials. This process involves aligning communication with insurers to confirm whether the patient is actually covered for the procedure. In other words, it ensures that the patient is an active policyholder and that their insurance covers the procedures they will undergo.
Main Consequences of Billing Denials
The primary consequence of billing denials is increased expenses, as the institution must cover the costs of services or procedures performed. If the volume of denials represents a significant portion of the organization’s revenue, billing can be severely impacted. If the hospital frequently fails to receive payments from insurers, patient care and services may be compromised.
When finances are affected, institutions may face shortages of supplies, reduced accessibility to services, and staff layoffs. All of this negatively impacts the institution’s reputation. But how can billing denials be avoided? An effective solution is the use of intelligent management systems that automate the validation of patient eligibility with insurers.
With these systems, data is automatically verified, ensuring smooth and accurate communication with insurers. Additionally, staff productivity increases since eligibility validation occurs in record time without human errors.
The result of this process is that the institution’s budget remains intact, preventing financial losses due to misalignment with insurers. Find out more about the relationship between digital tools and the reduction of administrative costs in healthcare institutions!
Patient Eligibility Criteria
According to the Brazilian National Health Surveillance Agency (ANVISA), eligibility criteria refer to a set of information used to assess whether a patient can receive certain treatments. For example, in cases of admission to an Intensive Care Unit (ICU), specific criteria must be evaluated to determine if the patient qualifies for hospitalization.
These criteria may include pulmonary diseases or emergency conditions. In the case of health insurers, patient eligibility criteria relate to the factors insurers consider when approving or denying a procedure.
For example, certain health conditions may prevent a patient from undergoing specific procedures. In general, insurers' eligibility criteria include the following aspects:
Age Range
Some laboratory tests and procedures cannot be performed on patients of certain ages, such as children or adolescents.
Pregnancy
Certain laboratory tests and procedures cannot be performed on pregnant women.
General Health Conditions
Depending on the patient’s current condition (chronic diseases, hypertension, etc.), some procedures may not be recommended or may require preliminary tests.
Medical History
A patient’s medical history must also be considered an eligibility criterion. This record indicates pre-existing health conditions that may prevent certain tests or procedures from being performed.
Medication Use
Depending on the type of medication the patient is taking, it may need to be discontinued before undergoing certain procedures.
Integrated Systems and APIs: Solutions for Automating Patient Eligibility Validation
Since billing denials are often caused by errors during manual data entry, it is crucial to minimize potential mistakes. Additionally, delays in authorization are another critical factor, as professionals spend excessive time accessing insurer portals and searching for patient data.
Technology optimizes this entire process, ensuring that patient eligibility is validated quickly. Integrated management systems, for example, allow for the collection, storage, exchange, and access to medical data in a secure digital environment.
By implementing these systems, your institution can increase productivity, reduce administrative costs, and minimize the risk of errors. To automatically validate patient eligibility and improve interoperability, you can integrate an API into your system that communicates directly with the insurer’s system. This solution facilitates data exchange between systems using different languages, providing greater security and accuracy in operations.
With this approach, eligibility validation is not only seamless and error-free, but patients can also be promptly directed to the appropriate procedures. This enhances the clinical experience and increases satisfaction with the service provided.
Key Benefits of Automating Patient Eligibility
By implementing a solution for eligibility validation and authorization of consultations and procedures, the likelihood of data entry errors is virtually eliminated, and approvals are obtained much more quickly. Here are the main benefits of this technology:
Elimination of Double Data Entry
By integrating the management system with the insurer via an API, your institution avoids duplicate data entry. When these solutions are not in place, staff must manually validate patient data on the insurer’s portal, re-entering information that is already in the management system. With integration, this process is fully automated, eliminating human errors.
Increased Productivity
By eliminating duplicate data entry, the validation process takes just about 30 seconds. With less time spent on administrative tasks, reception staff can serve more patients, optimizing institutional processes and resources.
Cost Reduction
Institutions significantly reduce administrative and operational costs by optimizing resources and service time. This also enables them to operate with a leaner team, generating substantial savings from a strategic management perspective.
Fewer Billing Denials
As mentioned earlier, reducing billing denials is one of the greatest challenges in healthcare. By automating consultation and procedure authorization, errors decrease, and institutions can receive payments from insurers without complications.
Conclusion
All these benefits highlight the importance of integrated solutions and intelligent systems for automatically and accurately validating patient eligibility. These advantages go beyond improving staff productivity and preserving the institution’s financial resources; they also enhance patient satisfaction and ultimately strengthen the clinic’s credibility.
Want to learn more about optimizing your institution’s financial flow? Discover how data tracking and control software can help eliminate billing denials.
About Pixeon
Pixeon is the company with the largest software portfolio for the healthcare market. Our solutions serve hospitals, clinics, laboratories, and diagnostic imaging centers, covering both management (HIS, CIS, RIS, and LIS) and diagnostic processes (PACS and Laboratory Interface), ensuring high performance and top-tier management in healthcare institutions.
The HIS/CIS software for hospitals and clinics, Pixeon Smart, is a complete solution that integrates the entire institution into a single system. It is also certified with the highest level of digital maturity by SBIS (Brazilian Society of Health Informatics).
We already have over 3,000 clients in Brazil, Argentina, Uruguay, and Colombia, serving millions of patients annually through our platforms.
Want to know if Pixeon’s technologies offer everything you’ve always wanted for your hospital or clinic? Request a commercial consultation and be amazed by everything our management system can provide!
