Enabling price transparency and optimizing patient coverage data

Challenge:

When a large southeastern health system implemented Epic, it saw significant productivity improvements as patient-facing teams were able to complete most tasks within the EHR. However, one workflow remained manual and problematic—eligibility and benefits. Patient facing teams were having to conduct multiple inquiries to get a full, complete understanding of a patient’s coverage, and they often had to go outside of Epic to validate data—or even call the payer for clarification. To improve the process, the revenue cycle team had two goals: 1) automate eligibility inquires so the results were directly integrated into the Epic workflow, and 2) improve the accuracy of the results.

Solution:

Availity worked with the health system to implement the Advanced Real-Time Eligibility solution within Epic across the organization, starting with the radiology department. With the Advanced Real Time Eligibility solution, the health system could directly connect to more than 600 payers in Availity’s nationwide network, delivering the most up-to-date results available. Additionally, the eligibility inquiry workflow was configured so that one request from the health system could be split into multiple requests to the payer based on service type codes, allowing for the return of a single, consolidated response. Not only does the response deliver better insight into patient coverage, but the health system is only charged for one inquiry and response transaction. And finally, because the results are integrated directly into their Epic workflow, staff members have the information they need when talking to the patient at the point of service.

Results

• Reduced operating costs by $2.3 million by automating and consolidating manualeligibility inquiries
• Returned 33% more procedure-specific benefit data by integrating the service type code functionality
• Reduced staff time by 25%