Experian Health Eligibility, also referred to as Insurance Eligibility Verification, is a core component of Experian Health's Patient Access and Revenue Cycle Management (RCM) suite. It is a Software-as-a-Service (SaaS) solution designed to automate the manual, error-prone process of verifying patient insurance coverage and benefits in real-time. The solution is crucial for healthcare providers, including hospitals, health systems, and medical groups, to ensure accurate billing and reduce the risk of bad debt and claim denials before service is rendered.
Key Features and Capabilities:
- Eligibility Clearinghouse: Connects to a vast network of over 900 payers, providing backup connectivity to minimize service interruptions.
- Real-Time Verification: Provides instant confirmation of a patient's active coverage, plan-specific benefits (like copays, deductibles, and coinsurance), and pre-authorization requirements.
- MBI Lookup Service: An automated Medicare Beneficiary Identifier (MBI) lookup service that helps find and validate missing or invalid MBIs to speed up Medicare reimbursements.
- Data Normalization and Enrichment: Standardizes patient information across all payer responses and enriches data with intelligence pulled from payer websites and other sources for more detailed responses.
- Bad Plan Code (BPC) Detection: Leverages technology like eCare NEXT® to promptly alert staff and prevent costly denials resulting from incorrect plan code usage on patient accounts.
- CAQH Coordination of Benefits (COB) Data: Integrates COB primacy information to increase accuracy and streamline the process for patients with multiple coverages.
- Automated Work Queues and Alerts: Streamlines staff workflow by providing immediate notifications that highlight important data requiring follow-up or edits.
Target Users and Use Cases:
The software targets large-scale healthcare organizations, including Hospital & Health Systems, Medical Groups, and Pharmacies & Diagnostics. Its primary use cases are to:
- Reduce Claim Denials: By verifying coverage and benefits up-front, it ensures cleaner claims submissions.
- Improve Cash Flow and Reduce Bad Debt: Real-time verification lowers financial risk and accelerates the payment cycle.
- Enhance Patient Experience: Enables staff to provide accurate, transparent cost estimates, which is critical for compliance with regulations like the No Surprises Act.
- Increase Staff Efficiency: Automation frees staff from time-consuming manual checks and phone calls to payers.
