Eligibility Verification Toolkit
Did you know your practice can realize nearly $4,000 in cost savings per physician by using electronic eligibility verification?Save money, reduce time, and improve service with electronic eligibility verification
How much time and money does your practice devote to verifying patients’ insurance eligibility and policy coverage? How much time does your staff spend on the phone with health insurers and other payers, waiting for responses, and filling out forms? If your answer is “too much,” electronic or electronic data interchange (EDI) health care eligibility requests and responses may be the solution. By adopting this method, your practice can:
- Submit an eligibility benefit inquiry (eligibility requests) and receive payer responses more quickly and accurately
- Identify primary care provider and other medical coverage
- Reduce claims rejections and avoid the collection and billing costs stemming from insurance verification errors
- Determine a patient's financial responsibility from information provided by the electronic eligibility response, to enable your practice to collect from patients at the point of care
- Apply your staff's valuable time and energy to revenue-enhancing activities, instead of spending time making phone calls to health insurers
- Save thousands of dollars per physician each year
Cost of paper eligibility verification: $3.70 x 1,250 = $4,625
Cost of electronic eligibility verification: $0.74 x 1,250 = $925
Average annual savings from electronic eligibility verification per physician: ≈$3,700*
* Based on an annual average of 1,250 verifications submitted for a single physician. Source: Milliman, Inc., “Electronic Transaction Savings Opportunities for Physician Practices.” Technology and Operations Solutions. Revised: Jan. 2006
Calculate your potential savings: View Aetna’s EDI savings calculator
By eliminating significant parts of the manual processes in an office’s routine, physicians can free their practice staff to perform other revenue-enhancing functions. Access the following educational resources “Information technology solutions: consider the potential savings” and determine your practice’s potential savings.
Access the AMA resource “Understanding the HIPAA standard transactions: The HIPAA Transaction and Code Set rule” for an overview of electronic health care transactions.
What is the purpose of the Accredited Standards Committee (ASC) X12 5010 270/271 health care eligibility benefit inquiry and response transactions (eligibility request and response), and the enhanced patient benefit and financial information being made available by the transactions?
Access an archived webinar, “Electronic eligibility request and response: Much more than ‘Yes, the patient is eligible,” which discusses the use and value of the enhanced eligibility request and response transactions.
Why adopt and use the full suite of electronic health care transactions? View the archived webinar Beyond the Claim: HIPAA 5010 Administrative Simplification Opportunities to Positively Impact your Revenue Cycle Management to learn more.
- What are the eligibility operating rules, and how do these rules enhance electronic eligibility verification? The Health Insurance Portability and Accountability Act (HIPAA) requires all covered entities to support requirements of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Operating Rules by January 1, 2013. Many health insurers already support the CAQH/CORE Phase I & II Operating Rule requirements. These operating rules enhance the information you receive from an electronic eligibility request. Access “What you need to know about electronic eligibility verification” to learn more about which requirements are included in the HIPAA-mandated operating rules.
- How can your practice use the information from an electronic eligibility response? The HIPAA-mandated Accredited Standards Committee (ASC) X12 270/271 health care eligibility benefit inquiry and response transactions (eligibility request and response) and operating rules will benefit your practice in its effort to collect payment from patients at the point of care. The enhanced standards and operating rules for electronic eligibility verification provide your practice with robust financial information such as copayments, coinsurance, and patient-specific remaining deductible, which can be used to calculate accurate point of care price estimations for patients so that your practice can collect from patients at the time of service.
"Considerations for processing electronic transactions in the physician practice” offers specific scenarios of how your practice might adopt electronic claims submissions, and provides additional considerations for your specific situation.
Take the brief Health Insurance Portability and Accountability Act (HIPAA) Transaction Code Set Vendor Survey to easily find out whether your vendors can process electronic claims and other health care transactions.
“Questions to ask a health insurer before enrolling in an electronic transactions program” outlines key issues with using electronic claims submissions that you need to carefully consider.
“Questions to ask a billing service before enrolling in an electronic transactions program” provides key questions to discuss with your billing service to understand how it can assist you in using electronic claims submissions.
“Questions to ask a clearinghouse before enrolling in an electronic transactions program” provides key questions to discuss whether your clearinghouse provides satisfactory functionality for electronic claims submissions.
Visit www.ama-assn.org/go/payerpolicies to access online resources from health insurers to help you move towards practice automation.
The suite of electronic health care transactions are designed to work together to create greater efficiencies for both physicians and health insurers. By adopting an integrated approach to using the electronic health care transactions, information gained from one transaction becomes useful information in the next transaction.
- Did you know that the increased use of electronic health care transactions in your practice, such as the electronic eligibility benefit inquiry and response transactions, has the potential to save physicians and health insurers nearly $30 billion per year? 
Access this case study to learn more about the savings your practice can experience using electronic health care transactions.
 U.S. Healthcare Efficiency Index, www.ushealthcareindex.com
Use the Health Insurance Portability and Accountability Act (HIPAA) complaint form to inform the AMA about health insurers and other payers that are out of compliance with the HIPAA electronic transaction and code set standards.