INSIGHTS

ACCURATE COVERAGE AND ELIGIBILITY INFORMATION FOR PROVIDERS AND PAYERS

Optimal coverage and eligibility information improves provider reimbursement, streamlines coordination of benefits for payers, and enhances the patient experience.

What is Coverage and Eligibility?

Why is Acquiring Accurate Coverage and Eligibility Information Challenging?

A Better Approach

The Benefits of Avaneer Coverage Direct

What is coverage and eligibility?

An individual’s health insurance can change many times throughout their lives. Coverage information explains if the patient has insurance, and with which insurance organization(s). Eligibility provides answers to the next set of questions regarding what services are covered, how much the patient and payer are responsible for paying, and whether or not the patient met the conditions to receive payment for this service. With annual enrollment requirements, coverage and eligibility details can change even when the carrier remains the same. In addition, many individuals have multiple payers through spouses, government programs, and other third-party liability payers, creating a challenge for patient access and billing teams. Providers and payers capture this information using coverage and eligibility tools.

Why is Coverage and Eligibility Information Important for Providers, Payers, and Patients?

Having accurate and complete coverage and eligibility information is crucial for providers and their revenue cycle teams to be able to bill the right payers with the correct information and get paid in full. Inaccurate or incomplete information can lead to denied claims, which can require hours of research to amend and resubmit. Denials can lead to reimbursement delays, lingering days in accounts receivable, and write-offs.

For payers, having accurate coverage and eligibility information is critical for effective coordination of benefits. Knowing about a patient’s additional coverage allows payers to coordinate and allocate responsibility for claim payments more effectively. This helps reduce overpayments, duplicate payments, and fraudulent claims while ensuring cost-sharing responsibilities are appropriately assigned.

When coverage and eligibility information is inaccurate or incomplete, it can cause delays in care, which can negatively impact outcomes and the patient experience. It can also cause patients to be billed for services that should have been covered or billed an incorrect amount, which can harm that patient-provider relationship.

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Accurate coverage and eligibility information is essential for timely reimbursement for providers, and for more effective coordination of benefits and accurate cost-sharing for payers.

Why is Acquiring Accurate Coverage and Eligibility Information Challenging?

A lack of interoperability and poor data latency between provider and payer systems leads to extensive lags in getting updated information on multiple coverages or changes in coverage status – creating a complex revenue cycle. Typically, patient access teams ask patients for their coverage and eligibility information either before or at the time of service. Then, they must verify this information, which often requires calling payers or searching payer websites for details. Many payers and providers have dedicated teams focused solely on research and verification of coverage and eligibility information.

For providers, when patient access teams don’t have the ability to capture complete, accurate patient coverage and eligibility data, they may experience denied claims, which can cause increased write-offs, delayed reimbursement, and lost revenue. The impact on payers is also significant, leading to inaccurate coordination of benefits, duplicate payments, and increased costs.

Coverage and eligibility information also impacts patient experience. When providers lack accurate information, it can cause delays in care which can negatively impact outcomes and cause patients to be billed for services that should have been covered.

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A Better Approach

With Avaneer Coverage Direct^TM, payers and providers receive automatic access to accurate, always up-to-date healthcare insurance coverage and eligibility information right in their own systems.

How it works

Coverage and eligibility data is converted into common FHIR® standards and an Avaneer ID is created and matched to other network participants who provide services to the same patient/member.
All instances of an individual’s coverage information are analyzed for discrepancies. If found, participants are automatically notified.
The updated coverage and eligibility information can be sent directly to the participants’ EHRs.

Coverage and eligibility data is shared directly between participants without third-party involvement.

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“Payers and providers owe it to their patients to work together to ensure timely access to care, fewer surprise bills, and a positive patient experience. Taking a new approach to coverage and eligibility data is a great place to start.”

David Schramm

Senior Product Manager at Avaneer Health

The Benefits of Avaneer Coverage Direct

Avaneer Coverage Direct reduces costs and administrative burdens for both payers and providers while also enhancing the patient experience. Because of the unique design of the Avaneer Network, data remains under the control of data owners and never has to leave that organization’s systems, which increases security and eliminates the need for third-party involvement.

Benefits for providers

Providers achieve immediate hard savings of up to $5.75 per claim by saving costs on:

Less denial rework
Fewer write-offs
Reduced bad debt and other uncompensated care
Fewer retroactive prior authorizations

Benefits for payers

Payers can benefit from lower costs as well—up to $1.65 per claim. These savings result from:

20% more net-new validated coordination of benefit (COB) leads
Improved claim adjudication and fewer manual verifications
Fewer provider calls into call center
Reduced recovery costs as part of payment integrity efforts

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With Avaneer Coverage Direct, accurate coverage and eligibility information is always available in real time without having to call payers or search payer websites, thereby reducing denials, takebacks, write-offs, and delayed payments while lowering revenue cycle management costs and improving the patient experience.