RPA use cases in Patient Eligibility

 Erika Regulsky RCM, RPA
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According to the 2021 CAQH index, eligibilityand benefits verification process is indicated to be the most expensive and cost burden administrative transaction for healthcare providers, hospitals, and health systems. Another research conducted by Becker’s Healthcare shows that 59% of hospitals and health systems are utilizing the advantage of robotic process automation (RPA) for the eligibility and benefits verification enabling this process to seek room for higher improvement. 

We have done research with our revenue cycle automation experts and our certified robotic process automation (RPA) experts and have come up with a beneficial use case of RPA in eligibility verification. BIllingParadise and our experts share their insights and use cases of how RPA in hospitals and health systems improved eligibility and benefits verification processes and revenue cycle management. BIllingParadise has 15 years of experience in the healthcare industry, including medical transcription, RCM, and healthcare IT. With that being said, let’s explore the RPA use cases in patient eligibility and benefits verification

How eligibility and benefits verification RPA impacts various aspects of RCM

You may wonder why the impacts of eligibility verification need to be presented in an RPA use case, understanding the problems before implementing RPA for eligibility verification would do wonders for a hospital or health system RCM and financial operations.

Eligibility and benefits verification is the first process of any healthcare organization is how healthcare organizations confirm the entire patient’s plan on information such as coverage limitations, out-of-pocket expenses like deductibles, copayments, and coinsurance with a patient’s health plan. Eligibility and benefits verification is a chief component of revenue cycle management without it physicians would blindly bill for the rendered services expecting whether the payment would be received or not. 

Typically healthcare systems and hospitals perform this repetitive and time-consuming task every time they receive a patient appointment or admission as a pre-registration/scheduling activity verifying eligibility throughout the revenue cycle process is a converging point to reduce denials, and underpayments/overpayments, AR (accounts receivable) days, and write-offs. The average cost of an inpatient hospital stay is now exceeding $2,600 per day, the cost of failing to verify eligibility and benefits can quickly escalate to unacceptable levels.

RPA use cases and practical implications in eligibility and benefits verification

Robotic process automation (RPA) is a technology that can replicate many activities of your health care operations staff or in other words “human-computer users” to complete routine clerical, analysis, data gathering, and other administrative tasks without human intervention. RPA bots are programmed robots that run continuously in the background, ensuring that repetitive, time-consuming, and mundane tasks are performed without the need for human intervention. RPA works 24/7 365 days around the clock, executing activities/tasks in a fraction of the time it would take by your hospital’s human staff.

Time and cost savings

Time & cost saving

Eligibility and benefits verification is a very labor-intensive and time-consuming task.it takes a human staff an average of 30mins to 1 hour in a patient’s account. Also, the costs of maintaining more eligibility staff will be overwhelming to hospitals, For instance, your hospital pays $3-$5k a month for front office staff and you would have to hire an extra 2-3 depending upon patient volumes you will be spending $160k on an average per year to check all the benefits and eligibility information using manual in house staff (FTE). Also if your eligibility team manually checks and re-checks multiple payer websites for each patient making it one of the complex patient data gathering processes. Robotic process automation (RPA) eliminates these time-consuming, repetitive tasks and opens opportunities for efficient eligibility re-checks, minimizing denial rates and reducing the cost to collect payment from insurance companies. As a matter of fact, eliminating manual human staff eligibility verification tasks saves providers 30 minutes per transaction.

RPA eligibility and benefits verification use case best practices

We requested our RCM and RPA experts to make sense of how robotic process automation (RPA) is best used to increase reimbursement repayment, avoid incorrect and late payments, decrease claim edit errors, and reduce administrative burden inside the eligibility and benefits verification process.

Pre-Registration verification

The reason why robotic process automation can verify the patient’s eligibility and benefits before the appointment during the RPA bots guiding process with the patient to set up appointments. This enables pre-definition of the patients plan benefits and puts a stop on future denials related to patient plan coverage, patient demographics etc. RPA bots stays one step ahead in denial prevention

Eligibility and benefits Re-Check

Eligibility re-checks is a must when it comes to analysing patients who have chronic conditions and obtain treatment for many years. Hospitals that treat such patients will have to re-check eligibility and benefits very ear

RPA bots will schedule automated eligibility checks for patients every year calculating the first new patient visit they had with your hospital. 

COB - Coordination of benefits verification

Patients have multiple plans supporting their primary by the means of cost-sharing to Secondary or tertiary payers. Most patients fail to verify this information during the visit. RPA bots will analyze the COB for the patient and automatically update the other payer data in the EHR under the patient account. HMO plans pay benefits on behalf of traditional plans like Medicare or Medicaid, this data is also updated and maintained by the RPA bots.

Benefit limitations

Benefit limitations are to be verified to prevent non-covered service denials. The American Hospital Association reports stated hospitals write off billions every year for not paying attention to benefit limitation details and end up using bad debt adjustments reducing collection rates for hospitals. RPA bots will ensure these benefit limitations are collected and logged accordingly for future reference. 

BillingParadise has already accomplished automating eligibility and benefits verification for many practices including larges dental groups and hospitals. They thrive with the use of automated eligibility checks and specialty-specific benefit information and are no longer blind to whether a particular service should be covered or not. As per the “no surprise act,” physicians are to provide detailed information and RPA eligibility and benefits use cases already demonstrating the cost, time, and payment benefits of implementing such RPA technology for your hospital. Have a conversation with our RPA experts and explore more about the beneficial use cases of robotic process automation patient eligibility and benefits verification.

 Appointment Scheduling using Robotic Process Automation

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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