shutterstock_104059577“Eligibility” is not what it once was! Commercial health plans have HMO’s and PPO’s and various other plan types, they also have various products within those categories, and just to make it more complicated some plans have plans within the plan specific to a given employer or group’s requirement. The Affordable Care Act has added to this confusion by adding more plan types, and those plans have various benefit calculations and yes, provider networks.

Even Medicare and Medicaid have plans within plans. A patient who presents with “Medicare” could have straight/traditional Medicare but they could also have a Medicare Advantage plan with a specific network. Medicaid now has commercial carriers and many have very specific networks of providers, and patients can move in and out of these plans frequently. All of these changes are designed to help control costs and direct patients to the right place.

(It’s not all bad thing – there is opportunity here – see below.)

Performing patient eligibility checks, in real time, is more important than ever:

  • Does the patient have the insurance they think they have?
  • Do they have the coverage they think they have?
  • Are they seeking care from the right provider?
  • Is your provider/practice in-network with the patient’s insurance?
  • Is the patient on an exchange plan? Have they paid their premiums (to ensure your provider will be paid for the services they provide)?
  • What is the patient’s co-pay, deductible and co-insurance, and what have they already met?

The good news: Most of this can now be automated! Many of the good clearinghouses have a component that checks patient eligibility. Most can be done in real-time with up to the minute check of benefits and participation in a specific plan. Most can also check to see if your specific services are in-network, allowed and payable. This can now be done with the click of (a few) key strokes and fast internet connectivity.

It takes good and conscientious staff, constant training of your staff (to stay on top of changes), and the re-design of some work flows and seamless systems that talk to each other. The other great thing about clearinghouses is that they report mistakes – those reports just have to be read, analyzed and used as a tool for process improvement.


With such sophisticated systems out there, practices now have the opportunity to collect for services up front (if deductibles and co-insurance are not met) instead of tracking down payment from the patient afterwards. This will result in increased revenue and cash flow for the practice! Dentist offices have done this forever – it is time for medical practices to do the same!

Health plans and payers of all sorts are looking for those who can be and are willing to be “Eligible” to provide cost effective care. It may not be reimbursed in the traditional fee-for-service method but these niche opportunities do exist!