How to Perform Eligibility Checks to Save Time and Money

There’s one question we’re often asked when it comes to eligibility checks: are they really worth it?

In a word…





HECK YES. (Okay, two words.)


Eligibility checks confirm what the patient is eligible for when it comes to benefits. They ensure the insurance is active and that the insurance company will be able to process the claims when they receive them. This is huge in terms of revenue retention.

Checks also give you upfront knowledge if the patient has a deductible, and if so, how much is remaining towards that deductible. You’ll learn about their copay, their coinsurance, and their bottom-line responsibility for their appointment.

Knowing this information and responding accordingly prevents you from a lot of collection efforts on the backend. By having your staff check eligibility on the front end, you won’t have to pay the billing staff later if a patient’s eligibility is different than what you expected. It also saves you from having to invoice for larger amounts on the backend.

The nutshell version? It saves you tons of time and money in the long-run to perform eligibility checks upfront. I’ve been working in medical billing for nearly two decades — trust me on this!

How to perform eligibility checks

There are many ways to perform these checks, depending on which systems you use in your office. Here are four ways, based on your system:

Fully integrated

If your software is fully integrated, performing eligibility checks could be as easy as a click of a button.

I recommend triggering an eligibility check before the day starts. This report can automatically note the patients on your schedule who don’t have active insurance coverage. So if they don’t hand you an updated insurance card when they check in, you can address it upfront.


If your software doesn’t have eligibility checks built-in, you can integrate your system with an online software. Most programs offer an add-on feature that sends patient information by way of an integrated tool. This functions in much the same way as fully integrated system, but it requires some setup on your part first.

Manual software checks

These checks are done completely outside of your patient software. Your staff will download your patient files and use an online software to enter the patient information. Once uploaded, they’ll send the information out and after a few minutes, they’ll get a list back of anyone who doesn’t have an active policy.

This might sound like a time-intensive procedure, but in reality is only takes about 15-20 minutes once the desk learns how to do it. I recommend doing this the night before, or in the morning before patients come in for the day. This way, you can respond appropriately if anyone’s insurance comes up as ineligible.

I recommend using the Trizetto-Gateway software for manual checks, because they have the ability to batch eligibility in their software, making it a quick process. IPS has a partnership with Trizetto-Gateway and offer our blog readers a fantastic discount — click here to learn more.

Availity is another program that can help you with manual eligibility checks. It isn’t as versatile as Trizetto-Gateway because it has limited connections, but it can definitely help to resolve whether patients are eligible. And it’s free for most providers.

Insurance company’s website or phone call

If none of the above methods float your boat, you can log into the insurance company’s website or call their IVR (interactive voice response) to check on each patient’s availability.

You’ll want to have the patient’s key information handy, to make this process as quick and easy as possible.

Although this method takes more time than some of the others, it still outweighs the costs associated with not performing eligibility checks!

Bonus tip: obtain detailed benefits

Eligibility checks are great, but they unfortunately don’t return every pertinent piece of information. If you’re a specialist’s office, you may want to go deeper so you can keep patients informed and charge them the correct amount.

For example, say a patient is referred to a speech therapist twice a week for 20 visits, but the insurance company will only cover 10 visits. If the front desk wasn’t aware of this, the patient would end up incurring a balance really quickly. Instead of insurance paying 100% with 10% copay, the patient could suddenly owe 50%, which would sour your relationship with that patient.

Getting as much detail as possible on your patient’s coverage prevents those unwanted surprises. I’d say about 80% of the time, getting detailed information on coverage involves a phone call to the insurance company. …Or, of course, you can hire IPS, because this is a service we offer! 🙂

The ultimate benefit of eligibility checks is a better relationship with patients. Patients never like to receive a call that they owe more money. They feel embarrassed when insurance companies call to say they owe money, and they then look at your office as the cause of that negative situation.

So you can keep your relationship with your patients strong, as well as save time and money, by performing regular eligibility checks. And when they’re so easy, why not?

Does your practice perform eligibility checks? What’s working for you, and what’s not? What system do you use? Share your ideas in the comments!

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JASMINE VJasmine Vializ is the President and CEO of Integrated Practice Solutions, a billing and practice management company designed to increase the quality of healthcare by helping doctors to prioritize their patients while boosting their bottom line.


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