The Challenge
A multi-facility hospital system was struggling to efficiently financially clear patients prior to their date of service.
Their pre-arrival workflows were fragmented across multiple systems, leading to:
- Day-of-service surprises, including unexpected balances
- Insurance plans that did not cover the services scheduled
- Missed opportunities to identify alternate coverage or set up payment arrangements
- Slow registration due to cutting/pasting data between siloed applications
- Increased errors caused by manual re-entry
- Limited visibility into where bottlenecks were occurring
The organization needed a unified, automated workflow that could validate coverage, calculate patient responsibility, identify financial risks early, and simplify the payment process — all before the patient arrived.
The Solution
We deployed an integrated pre-arrival automation solution encompassing insurance verification, coverage discovery, medical necessity checking, authorization automation, financial screening, and payment enablement.
Key Components:
- Real-Time Insurance Verification: Validated benefits instantly and ensured coverage applied to the specific services ordered.
- Coverage Discovery: Searched for unreported Medicare, Medicaid, or commercial coverage and fed results back into the verification workflow.
- Automated Preauthorization: Submitted requests electronically, captured responses, and monitored “pending” statuses—eliminating manual portal checks.
- Medical Necessity Validation: Ensured services met payer criteria and generated ABNs/medical necessity forms at registration and discharge.
- Price Estimation Integration: Connected directly with the client’s estimation vendor to calculate accurate patient out-of-pocket costs and surface them to registrars in real time.
- Financial Screening: Identified Medicaid, charity care, or other eligibility programs the patient might qualify for, enabling early referral.
- Payment Collection Integration: Integrated the hospital’s payment acceptance system so registrars could take payment or establish payment plans during the pre-arrival call or at check-in.
Together, these components formed a unified, efficient pre-arrival clearance workflow, replacing multiple disconnected tools with one streamlined solution. By proactively managing deficiencies, the system ensured that work was prioritized and completed prior to the patient’s date of service.
Impact / Results
Operational Efficiency
- Reduced manual data entry and eliminated the need for staff to cut/paste across systems
- Faster patient registration with fewer errors
- Streamlined authorization and verification processes reduced staff workload
Financial Performance
- Fewer day-of-service denials caused by incorrect or unverified coverage
- More accurate patient responsibility estimates improved upfront collections
- Increased identification of alternate coverage reduced bad debt and charity write-offs
Patient Experience
- Patients received clear expectations of their financial responsibility before arrival
- Fewer surprises improved satisfaction and trust
- Payment plans and eligibility screening offered support for patients with high balances
Organizational Outcomes
- A unified, automated solution reduced dependence on legacy tools and disjointed processes
- Improved compliance through accurate form generation and documented medical necessity
- The hospital gained a scalable foundation for ongoing revenue cycle improvements