Billing and Compliance AutomationPurpose
1.2. Enable front-office, billing teams, and clinicians to detect authorization needs, reduce claim denials, and automate notifications for patients and providers.
1.3. Integrate eligibility checks with EHR/EMRs, clearinghouses, patient onboarding, scheduling, and claim submission systems.
1.4. Aggregate verification logs for audit trails and compliance reporting (HIPAA, payer contracts).
1.5. Enable multi-payer, multi-plan check for out-of-network, deductible, copay, and pre-certification requirements specific to anesthesia billing.
Trigger Conditions
2.2. Patient demographics or insurance details are added/changed in practice management system.
2.3. Scheduled surgery or anesthesia procedure entered into OR scheduling module.
2.4. Batch trigger for all next day/week scheduled cases.
2.5. Manual eligibility check requested by billing staff.
2.6. Automated re-verification when initial check is inconclusive or near procedure time.
Platform Variants
3.1. Change Healthcare
- API: Real Time Eligibility & Benefits (270/271)
- Configure integration with provider/facility NPI and payer ID.
3.2. Availity
- API: Real-Time Eligibility and Benefits
- Use Availity API credentials for insurance lookup endpoints.
3.3. Waystar
- Feature: Eligibility Verification API
- Set up batch or single-patient eligibility queries by NPI.
3.4. Emdeon (Change Healthcare clearinghouse)
- API: Eligibility Web Service
- Pass patient, payer, provider details via XML/SOAP.
3.5. Experian Health
- Feature: Eligibility Verification Service
- Integrate SFTP/API connection for insurance lookups.
3.6. Eligible
- API: /eligibility endpoint
- Use practice keys to batch patient eligibility requests.
3.7. PokitDok
- Endpoint: Eligibility API
- Patient, Provider, and Payer data in REST call.
3.8. TriZetto (Cognizant)
- Feature: Real-Time Eligibility API
- Requires payer/plan mapping for anesthesiology.
3.9. Greenway Health
- Interface: Eligibility Verification Module
- Sync eligibility check to patient chart event.
3.10. Epic (EHR)
- Feature: Real-Time Benefit Check
- Use App Orchard APIs within Hyperspace and linked clearinghouses.
3.11. Cerner (Oracle Health)
- Feature: Eligibility and Coverage API
- Trigger on surgical order entry or appointment.
3.12. Allscripts (Veradigm)
- API: Real-Time Eligibility
- Integrate through Practice Management scheduling workflow.
3.13. McKesson RelayHealth
- Feature: WebConnect Eligibility Service
- Configure per anesthesiology specialty rules.
3.14. Availity Essentials Pro
- API: Eligibility & Benefits Inquiry
- Link to payer-specific specialty rules for anesthesia.
3.15. AdvancedMD
- Feature: Insurance Eligibility Autocheck
- Schedule via patient registration event.
3.16. Athenahealth
- Endpoint: /v1/{practiceid}/insuranceeligibility
- Cron trigger for next-day surgery patients.
3.17. Salesforce Health Cloud
- Feature: External Services (Eligibility API)
- Integrate via invocable flows tied to patient records.
3.18. MuleSoft
- Connector: EDI X12 270/271 Real-Time Eligibility
- Workflow: On patient scheduling data ingestion.
3.19. NextGen Healthcare
- Feature: Insurance Eligibility Interface
- Fire rule when anesthesiology procedure booked.
3.20. Meditech Expanse
- Feature: Insurance Eligibility Query
- Linked to OR scheduling and registration.
3.21. Rhapsody Integration Engine
- API: Eligibility Check transformation
- Middleware event on HL7 ADT or ORU message trigger.
3.22. Redox
- API: Eligibility Data Model
- Trigger with surgery scheduling integration event.
Benefits
4.2. Improves patient experience through upfront coverage confirmation and financial transparency.
4.3. Accelerates scheduling, authorization, and preoperative workflow efficiency.
4.4. Enhances compliance with payer, CMS, and audit requirements.
4.5. Supports multi-payer, procedure-specific coverage needs unique to anesthesiology practice.
4.6. Frees staff time for higher value tasks and reduces costly manual calls or web lookups.