According to Experian Health’s State of Claims 2024 survey, missing coverage is the top reason for healthcare claim denials for almost a fifth of providers. However, the issue isn’t just about whether a patient is insured — four in ten providers worry about insurance companies paying out even where patients have active coverage. Constantly changing payer policies can result in altered or expired benefits, leaving providers scrambling to secure alternative sources of payment. That’s why many providers are turning to automated health insurance discovery to find missing coverage and catch outdated policies early.
This article looks at how coverage discovery software helps healthcare organizations address some of the most stubborn pain points in the revenue cycle.
What is health insurance discovery?
When a patient comes in for care, one of the first jobs is to figure out exactly what insurance they have — if any — and what it covers. Health insurance discovery is the process of checking whether the patient has active insurance and confirming details of that coverage, such as payer name and plan type, to ensure the cost of care is billed to the correct payer. If a patient has multiple active plans, the provider must also determine how much should be billed to each payer and in what order.
How does it work?
Ideally, coverage discovery occurs pre-service, but it can occur later if a claim is denied, and alternative coverage sources must be found. The main steps in the process include:
- Collecting insurance details when patients schedule or check in
- Checking with insurance companies to confirm that coverage is active and will cover planned services
- Cross-checking payer databases to ensure no coverage is missed
- Considering a patient’s eligibility for Medicaid or other charity support
- Coordinating benefits for accurate billing
Benefits of automated health insurance discovery for providers
While respondents to the State of Claims survey are reasonably confident about their coverage discovery processes, the actual outcomes are less robust. Eligibility checks are taking longer and errors are on the rise. Only 54% of providers believe their claims technology can meet current revenue cycle demands. Automation offers a reliable and adaptable solution to bridge the gap between front-end checks and back-end claims management.
Here are a few ways automated health insurance discovery sets the stage for smoother claims submissions and revenue cycle performance:
1. Maximize reimbursement by finding missing coverage quickly
Challenge: Patients don’t always provide complete insurance information, which can cause providers to miss out on opportunities for reimbursement.
How automation helps: Automated health insurance discovery digs deeper than manual processes to find any coverage that may have been missed or forgotten. Experian Health’s Coverage Discovery® solution combs through multiple proprietary databases, including employer information, historical search information, registration history and demographic validation to proactively identify billable Medicare, Medicaid, and commercial coverage. With minimal patient details, it finds additional sources of primary, secondary and tertiary insurance instantly.
In 2023, Coverage Discovery tracked down previously unknown billable coverage in a third of patient accounts, resulting in more than $25 million in found coverage.
2. Reduce the manual workload
Challenge: Staff spend too much time calling payers, logging into portals and manually entering patient data. This is time-consuming and error-prone, especially when one in four resubmissions are worked on by a different person than the one who originally processed it.
How automation helps: Automation eases the admin burden by handling repetitive aspects of insurance verification behind the scenes, freeing staff to focus on more complex tasks. Coverage Discovery saves staff time by continuing to check for health insurance throughout the patient journey, and not just at registration. This final post-service check is vital to detect discrepancies that could lead to denied claims. Staff can also automate the self-pay scrubbing process to further reduce the risk of errors. As providers continue to feel the squeeze from staffing shortages and rising operating expenses, any move to reduce costs while bringing in more revenue is to be welcomed.
3. Prevent eligibility issues
Challenge: Providers often only discover that active benefits have changed after the claim has been submitted. That’s too late. For 43% of providers, it takes at least 10 more minutes to check eligibility when initial checks are incomplete.
How automation helps: With automation, providers can run real-time eligibility checks, ensuring that changes to the patient’s benefits are caught early so claims aren’t denied due to outdated information. Experian Health’s new Patient Access Curator uses artificial intelligence-based data capture technology to return accurate information from multiple sources with a single click. It automatically interrogates data from more than 270 payer responses, including active and billable coverage, plan level detail, chaining and primacy, so providers can verify eligibility and more in an instant.
4. Reduce claim denials and rejections
Challenge: Incorrect or incomplete insurance information results in errors on claims forms or claims sent to the wrong payer, which causes denials, delays and rework.
How automation helps: Automated discovery ensures that the correct payer and coverage information is attached to claims, reducing the likelihood of denial. This solves one of the most frustrating parts of coverage discovery, making the process faster, more accurate and less reliant on manual effort.
Read more: How to leverage AI and automation to minimize healthcare claim denials
5. Improves the patient experience
Challenge: Patients are often confused about their coverage status and worried about whether their healthcare costs will be met by their insurance provider.Medicare beneficiaries, in particular,report difficulty understanding and comparing plan options, leading to potential gaps in coverage.When healthcare providers fail to catch errors or gaps in their information, this erodes trust and negatively impacts how they feel about their experience.
How automation helps: By correctly identifying coverage and verifying benefits eligibility, automation allows providers to give their patients early certainty about how their healthcare costs will be covered. Patients are less likely to receive unexpected or incorrect bills, which prevents delays and disputes. Automated tools can go a step further to improve the patient experience by guiding patients toward additional support and payment plans. For example, Patient Financial Clearance identifies patients who may be eligible for Medicaid or charity assistance, and identifies appropriate payment plans for anyone with an unmanageable self-pay balance.
Case studies: See health insurance discovery in practice
- How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks
- How UCHealth secured $62M+ in insurance payments and saved $3.5M+ in 2022 with Coverage Discovery
- How Luminis Healthused Coverage Discovery to find $240K in billable coverage each month
Learn more about how automated health insurance discovery helps providers reduce claim denials, improve cash flow and deliver better patient experiences.
