Context
A senior healthcare provider delivers personalized in-home care to patients through physicians, nurse practitioners, and physician assistants. Before every patient visit, the company is required to verify the patients' insurance coverage. This verification process is critical to determining which services are covered by the patient's insurance and what the patient owes. If verification fails or arrives late, appointments get canceled, and as a result, quality in-home patient care gets delayed.
This verification process is central to the overall operational efficiency of the business. Speed and accuracy significantly impact patient satisfaction and the provider's ability to bill for services delivered. For an organization providing in-home care to thousands of active patients, even marginal improvement to this process has exponential benefits throughout the entire operation.
Problem
The benefits verification process was manual, which consumed a tremendous amount of company time. In addition to pulling a patient's information from one system, the personnel had to contact insurance companies by phone to verify coverage and enter response into another system. This way, each patient had to be handled at least two times a day.
The scope of the problem was substantial. The company verified 9000 patients' coverage monthly. It took 25 minutes to verify each individual. A team of 25 FTEs worked full-time on this single task.
Delays rippled throughout the organization. Until coverage was confirmed, patients could not be scheduled. With confirmation taking days or hours, appointment slots remained empty. Errors caused an additional layer of problems. Wrong entries into the system resulted in claims being denied. Patients received unexpected medical bills for services that they believed would be covered by their plan.
The security risks were considerable. Twenty-five employees had access to patient medical records and insurance information on multiple occasions. Each human interaction created an opportunity for data breaches and compliance violations.
The specific challenges included:
- Manually extracting patient and insurance data from existing systems
- Entering data multiple times created room for errors or omissions
- Scheduling delays when verification could not be completed in time
- Lack of transparency into which verifications were completed at the time of patient visit
- High error rates leading to denied claims and subsequent patient billing issues
- Multiple employees had access to patients' highly sensitive healthcare information
Solution
Cloud Maven implemented Medical Insurance Verification, an automated verification system built within the provider's existing patient platform. The tool connects directly to insurance carriers and retrieves real-time coverage information with a single action.
For new patients, the system uses Optical Character Recognition (OCR) and AI to read insurance cards and state identification. Patient and insurance details are then automatically populated into the correct Salesforce records and fields. For existing patients, the system runs verification checks at set intervals prior to the upcoming scheduled appointment, typically on the day of the service. Coverage information returns instantly and updates the patient record.
Any accounts unable to be processed through the automated feature are immediately assigned to a small team for review. The list view allows users to see which patient profiles require manual reviews. The system routes these exceptions to the appropriate personnel without requiring manual task assignment.
Cloud Maven, Inc transformed a labor intensive manual process into a simple, automated workflow using Medical Insurance Verification.
Implementation
Cloud Maven, Inc automated the end-to-end insurance verification workflow using multiple integrated accelerators within Salesforce. Fax Hub and Secure Email enabled secure patient communication, Document Insight used OCR and AI to extract insurance card and patient information, and Medical Insurance Verification automatically verified coverage during patient intake and again on the date of service.
The implementation included training for all staff members and close coordination between company’s billing and scheduling departments. After the launch, the technical support from Cloud Maven, Inc continued to help solve any issues that arose.
Results
The use of an automated eligibility system has changed how the provider verifies patient benefits. What used to require a large team of 25 people working all day long now can be accomplished by a small team.
The outcomes were transformative:
- Reduced staffing from 25 to 5 full-time employees, with annual cost savings of $1.2 Million
- Verification processing shifted from days to real-time completion
- Provider scheduling improved by matching actual visits with booked appointments
- Claims denied due to coverage error decreased by 90%
- New patients can be scheduled on same day
- Centralized verification within one system improved HIPAA compliance and reduced data breach risk
Cloud Maven, Inc understood our business model and the time pressure we were under. They got the system running quickly and their ongoing support has been invaluable.
Senior Healthcare Provider
