SolutionsEligibility verification
Eligibility verification
Confirming coverage before the encounter, not after the denial.
Why this one
costs you money.
Eligibility is the cheapest point in the cycle at which to prevent a denial, and the easiest to skip — because skipping it costs nothing on the day. The cost arrives weeks later, as a denial, a write-off, or a balance the patient never expected and will not pay.
Verification confirms that the coverage exists, that the plan is active, that the service is covered and that any required authorisation is in place — before the encounter, while all of it can still be fixed.
What this discipline
actually involves.
- Coverage, benefits and plan status confirmed ahead of the visit.
- Prior-authorisation requirements identified before care is delivered.
- Patient responsibility established early enough to be communicated.
- Secondary and tertiary coverage identified up front.
- Verification failures treated as a front-end defect, not a billing one.
The method.
Verify coverage
Plan status, effective dates and coverage of the specific service are confirmed ahead of the visit, against the payer rather than against what is on file.
Check authorisation
Prior-authorisation requirements are identified before care is delivered. Care given without a required authorisation is frequently unrecoverable at any later point.
Establish responsibility
Deductible, co-insurance and co-pay are established early enough to be communicated to the patient before the visit, rather than billed after it.
Identify other coverage
Secondary and tertiary coverage is identified up front, so coordination of benefits does not resurface later as a denial.
What you receive
- Coverage confirmed before the encounter, per visit.
- Authorisation requirements flagged ahead of care.
- Patient responsibility established pre-visit.
- Verification failures reported as a front-end metric.
The failure modes.
Checked too late, or not at all
Verification gaps do not look like a problem on the day. They surface weeks later as write-offs.
Missing prior authorisation
Care delivered without a required authorisation is often unrecoverable.
Patient responsibility discovered after the visit
Collecting after the fact is far harder than collecting at the desk.
What clients say.
Eligibility verification was an area where we knew we had room for improvement. Exact Core helped us establish a more consistent process for identifying coverage issues before they became billing problems.
As our practice grew, managing the revenue cycle became increasingly complex. Exact Core gave us the additional structure and expertise we needed without requiring us to completely change the systems we already had in place.
About eligibility verification.
How far in advance is eligibility checked?
Far enough ahead that a problem can still be solved — typically when the appointment is booked, and re-checked close to the visit, because plans terminate and change between the two.
Why re-check if coverage was verified last month?
Because coverage is a point-in-time fact. Plans terminate, employers change carriers and deductibles reset. A verification from last month describes last month.
What if the patient has no active coverage?
It is far better to know before the visit. The practice can then discuss self-pay, reschedule, or help the patient resolve the coverage problem — all options that disappear once care has been delivered.
Does this include prior authorisation?
Identifying that an authorisation is required is part of verification. Obtaining and tracking it is closely related work, and is scoped alongside it.
The other five disciplines
Revenue leaks between them, which is why they are managed as one cycle.
Medical billingMedical codingDenial managementAR ManagementCredentialingPatient supportFront office management
How is eligibility verification
performing for you?
A revenue assessment reviews all eight disciplines end to end and shows you where the reimbursement is going.