Enhancing Operational Efficiency: Real-Time Patient Eligibility and Claims Checks for Medical Practices

Patient eligibility verification and claims status check complexities often become a sizable burden for medical practices. This is because mistakes or inefficiencies in eligibility verification and claims tracking lead to denied claims that result in revenue loss. 

Howver, purpose built healthcare applications can help medical practices eliminate these errors that lead to revenue bleed. Real-time patient insurance eligibility verification and claims status checks hold immense promise for medical practices to enhance precision, cost-effectiveness, and speed in the insurance verification and claims check process. 

The Potential of Real-Time Patient Eligibility Verification for Medical Practices  

To truly understand the immediate benefits associated with going 'real-time,' it is imperative for medical practice owners to understand how it outweighs the traditional patient insurance eligibility verification process. With healthcare IT spearheading the healthcare industry's transformation as we know it, contemporary approaches to simple problems often lead to blitzkrieg advantages. Real-time patient eligibility verification is one such feature that contains the immense potential to save time and costs for medical practices. The following are some areas in which real-time patient eligibility verification makes an impact:

The Impact of Patient Eligibility Verification Mistakes on Claims Management 

Mistakes in verifying patient eligibility have considerable repercussions for both healthcare providers and patients. Inaccuracies, such as supplying incorrect insurance details or overlooking coverage updates, can lead to unfavorable consequences, including claim denials, delayed reimbursements, and increased administrative challenges for healthcare facilities. For practitioners, these errors jeopardize the financial viability of their practices and impede the punctual provision of care to patients. Here are some of the common errors that frequently lead to denied claims. 

  • Incorrect Patient Information
  • Coverage Discrepancies
  • Inadequate Benefit Verification
  • Inaccurate Provider Information
  • Lack of Pre-Authorization
  • Failure to Verify Referral Requirements
  • Overlooking Patient Financial Responsibility

The No Surprises Act: Mandates for Medical Practices

The ‘No Surprises’ Act was enforced in 2022 to establish legal requirements to safeguard patients and consumers from unexpected and distressing medical bills. Inaccurate payer network status and frequent referrals to out-of-network providers have often impacted patients leaving them in financial distress. Recognizing the need to prevent unforeseen financial burdens on patients, the ‘No Surprises’ Act introduces mandates and regulatory guidelines to curb excessive out-of-network billing. These regulations are equally pertinent to medical practices.

The legislation brings forth the notion of Good Faith Estimates (GFE) to communicate to patients the expected expenses associated with a planned or requested healthcare item or service. These estimates should encompass all aspects of the encounter, incorporating any services from other providers or facilities. However, due to the intricate and comprehensive nature of the law's stipulations, ensuring transparency in this context may occasionally feel like navigating through a complicated and demanding procedure.

The United States Department of Health and Human Services (HHS) is dedicated to prioritizing patients in their care journey, with the ‘No Surprises’ Act standing as a key initiative. Central to its mandates are Good Faith Estimates (GFEs) and a proactive communication approach, serving as the foundational principles. 

The mandates are as follow:

  • Disclose Benefits, Protections and Stats Costs
  • Determine the Patient Rights Bestowed by the No Suprists Act
  • Notify Patients of Their Right to Good Faith Estimate (GFE)
  • Balance Billing Restrictions
  • Provide Accurate GFEs on Time and in Good Detail

What Your Ideal Patient Eligibility and Claims Check Tool Must Look like 

The decision between Insurance Verification Portals and Real-Time Eligibility Verification plays a crucial role in patient insurance verification. While self-service portals have their advantages, real-time verification stands out as a transformative option, providing medical practices with a dynamic and proactive approach.

On the other hand, post-patient care, the administrative staff often faces the challenge of regularly checking claims status through multiple web portals. This cumbersome task can be streamlined by incorporating RTE applications into medical practices. However, selecting the application that aligns with the medical practice's specific needs is essential for maximizing the Return on Investment (ROI) from your chosen solution. The following are some of the essential features practice owners must look for in their patient eligibility and claims check application

  • Real-Time Verification
  • Decluttered UX and Customizability
  • Customized Reporting
  • Seamless EHR Integration
  • Claim Tracking and History
  • In-App, Usability Hints
  • Batch Processing
  • Role-Based User Access Control

Ensuring Seamless Healthcare: Best Practices of Patient Eligibility Verification

Successful patient eligibility verification is not limited only to using an application that verifies patient health insurance eligibility in real time. It comprises the ideal balance between application functionality and staff efficiency. By establishing clearly defined workflows and guidelines, medical practices can ramp up their claims approval rates:he following are some of the best practices:

  • Establish Clear Communication Channels
  • Verify Insurance Coverage Before Services
  • Educate Staff on Insurance Policies and Changes
  • Implement Quality Control Measures
  • Utilize Predictive Analytics for Risk Mitigation
  • Foster a Patient-Centric Approach
  • Embrace Technology for Accuracy and Efficiency


The healthcare industry is slowly but steadily transforming into a patient-centric industry. With the Office of the National Coordinator (ONC) and the Center for Medicare and Medicaid service gunning for perennial regulations to extract more value from the care process, healthcare applications such as real-time patient eligibility verification and claims check tools are playing a central role in eliminating revenue cycle conundrums.