Some of the most expensive revenue cycle problems start before the patient is seen. When coverage isn’t verified or an authorization is missing, the claim is likely to be denied, and some of those denials can’t be recovered at all.
How eligibility problems cost you
- Claims denied because coverage ended or the patient changed plans.
- Claims sent to the wrong payer, or with primary and secondary coverage reversed.
- Patient responsibility that wasn’t known at the visit, so it wasn’t collected then.
- Staff time spent tracking down the right payer weeks later, when filing deadlines are closer.
How authorization problems cost you
A missing or expired authorization often leads to a denial that is hard to overturn. Some payers allow retroactive authorization in limited cases; many don’t. And because in-network contracts often prevent billing the patient for a service denied for lack of authorization, that revenue may simply be lost.
Verify eligibility before every visit
- Check eligibility through the payer portal or your practice management system a day or two before the visit.
- Confirm the plan, effective dates, copay, remaining deductible and any other coverage.
- At check-in, ask whether anything has changed and scan the card again.
- Re-check recurring patients regularly, especially at the start of the year and after open enrollment.
Build an authorization workflow
- Keep a list of the services and payers that require authorization, and update it when payer policies change.
- Check requirements when the visit is scheduled, not at check-in.
- Track approved units or visits and expiration dates.
- Put the authorization number on the claim.
- Request extensions before approved visits run out.
Tell patients what they owe up front
Eligibility checks show copays, deductibles and coinsurance. Share an estimate before or at the visit, and collect known amounts at check-in. Patients are more likely to pay when they know what to expect, and it keeps those balances out of A/R.
Measure the impact
Track denials for eligibility and authorization reasons as a share of all denials. Reason codes such as CO-27 (coverage ended) and CO-197 (authorization missing) point to these. If they make up a large share, the fix belongs at the front desk, not in the billing office.
Insurance verification is part of Ace’s medical billing service, and our denial management team works the eligibility and authorization denials that still come through.