Automated insurance eligibility verification

Purpose

1. Automates real-time verification of patient insurance eligibility prior to appointments to prevent claim denials, reduce admin workload, optimize billing cycles, and ensure patient coverage aligns with endocrinology service requirements.

2. Ensures up-to-date coverage information, co-pay, deductible, and benefit details are synched prior to treatment.

3. Enables automated updates to EHR/EMR and billing workflows for endocrinologists, reducing manual errors, and improving patient experience.

Trigger Conditions

1. New appointment scheduled in practice management software.

2. Patient demographic or insurance information changes in the EHR.

3. Periodic batch checks (e.g., daily for next-day appointments).

4. Submission of insurance details via patient intake forms.

5. Manual request by staff for eligibility re-verification.

Platform Variants

1. Availity

• Feature/Setting: Eligibility and Benefits API — configure with practice NPI, payer ID, and patient subscriber information for automated eligibility request/response.
  

2. Change Healthcare

• Feature/Setting: Real-Time Eligibility Verification API — connect using practice credentials, automate API calls daily for scheduled patients.
  

3. Experian Health

• Feature/Setting: Eligibility Verification Web Service — set rules to automate checks 1 day before all endocrine consults.
  

4. Office Ally

• Feature/Setting: Practice Mate API for eligibility — automate calls upon new patient registration.
  

5. Greenway Health

• Feature/Setting: Intergy EHR API, automate triggers when a scheduling event is recorded for endocrinology appointments.
  

6. Epic Systems

• Feature/Setting: App Orchard FHIR Endpoints, automate eligibility tasks anytime insurance is updated.
  

7. eClinicalWorks

• Feature/Setting: eEHX APIs, configure to trigger automated eligibility requests based on custom patient queries.
  

8. athenahealth

• Feature/Setting: athenaAPI Eligibility endpoint, automate batch triggers for endocrinologist schedules.
  

9. Cerner

• Feature/Setting: HealtheIntent API, schedule automated eligibility pulls on a nightly basis.
  

10. Allscripts

• Feature/Setting: Open API — automate calling eligibility check logic for all endocrine department bookings.
  

11. Salesforce Health Cloud

• Feature/Setting: OmniStudio Integration — automate eligibility status lookup based on patient record changes.
  

12. Health Gorilla

• Feature/Setting: Eligibility API — automate patient insurance validation at intake.
  

13. Eligible

• Feature/Setting: Real-Time API, automate eligibility check when patient record is updated in EMR.
  

14. PokitDok (now Change Healthcare)

• Feature/Setting: Eligibility API, automate via main API endpoint for endocrinology-specific NPI calls.
  

15. Meditech

• Feature/Setting: RESTful APIs for insurance management, automate eligibility verification on scheduled events.
  

16. OpenEMR

• Feature/Setting: X12 270/271 integration, automate sending 270 requests on new appointment.
  

17. DrChrono

• Feature/Setting: Insurance Eligibility Endpoint, automate on appointment creation for endocrinology.
  

18. Kareo

• Feature/Setting: Insurance Eligibility API, automate eligibility requests on insurance change events.
  

19. AdvancedMD

• Feature/Setting: Insurance Eligibility Service API — automate nightly batch for next day’s endocrine appointments.
  

20. NextGen Healthcare

• Feature/Setting: Insurance Eligibility Automated API, initiates checks for any schedule modification in endocrinology.
  

21. Insync Healthcare Solutions

• Feature/Setting: Eligibility APIs, automates eligibility review on billing submission creation.
  

22. Zebra Medical Vision

• Feature/Setting: Integration with payer portals, automate eligibility verification prior to DEXA scan appointments.
  

Benefits

1. Automates the redundant, error-prone eligibility process for endocrinology practices.

2. Automatedly mitigates claim denials and reduces reimbursement cycle delays.

3. Automator decreases staff time on phone or portal logins, automating repetitive data entry.

4. Automatable capture of precise patient coverage, deductible, and copay info for accurate upfront collections.

5. Automating builds patient trust with transparent, rapid coverage feedback.

6. Automated data synchronization minimizes billing bottlenecks and downstream rework.

7. Automation elevates compliance by ensuring eligibility is always current before service delivery.

8. Automates process scaling as endocrinology clinics grow, supporting higher patient throughput with same administrative headcount.