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Idea and Inspiration

bigstock-Falling-From-Chair-8001787.jpgHow much time do you spend each week verifying patient eligibility? Do you spend hours calling insurers to confirm policy information and coverage? Do you wait for responses, fill out forms and generally spin your wheels when it comes to eligibility verification? If you’re nodding along as you read this, you’re not alone.

Eligibility verification is a crucial aspect to running a business whether you work for a billing company or physician’s practice. With an additional 30 million uninsured Americans now receiving healthcare coverage under the Affordable Care Act, verifying procedure benefits, prior authorizations, referral requirements if applicable, and covered and non-covered conditions for certain procedures is imperative. Without such verification, you will likely experience high levels of insurance denials and lost revenue. Eliminate the possibility of uncollectible revenue from patients with invalid or insufficient insurance benefits – let the experts here help you!

We’ve been around the block and have helped numerous practices and companies get on the right track with eligibility.

In fact, we frequently hear of many misconceptions when it comes to eligibility checking. While these may seem harmless, or like “no-brainers,” these misconceptions can actually hurt your workflow and revenue. For example:

Misconception #1: Clearinghouses have all the answers.

Unfortunately, this just isn’t true. Clearinghouses certainly have an enormous amount of information and technical capabilities to gather some eligibility information, but it isn’t guaranteed to be accurate or thorough enough. To get speedy and accurate verification, you need live representation and phone calls from knowledgeable professionals (like us!).

Misconception #2: The EHR has all the information I need.

Anytime an EHR allows you to have Level 1 verification, it’s very basic. Too basic, in fact. You will likely not have access to specific diagnostic codes and procedures. This obviously creates long-term problems for patient data records and insurance coverage.

We explore more on the topic of eligibility below.

Enjoy this month’s ClinicSpectrum newsletter. As always, we appreciate your feedback. Please reach out if you have comments or suggestions.


Vishal.jpgVishal Gandhi
CEO, ClinicSpectrum



Garden State Cardiovascular, a ten-physician practice located in Linden, New Jersey, has been a ClinicSpectrum customer since March of this year. Helen Diaz, Billing Manager/Office Manager for the practice, credits a more streamlined and thorough billing process to the use of ClinicSpectrum’s Accounts Receivable follow-up services.

“We had lost nearly 30 percent of billable income when we were using a different vendor,” said Diaz. “ClinicSpectrum is helping us to recoup that and ensure no balls are dropped.”

With more than 90 patient visits on a daily basis, Garden State Cardiovascular needed help, specifically in its billing department, to ensure a steady stream of revenue while maintaining a hefty schedule of appointments.

“ClinicSpectrum has not only helped by taking an incredible burden of work off of our plates, but they are incredibly helpful,” said Diaz. “If ever we have questions, we can always reach someone who will get us answers quickly.” 


Billing in the healthcare industry + insurance claim denials = TOTAL headache.

The process of initial claim submission is lengthy and complicated enough – put the resubmission of a claim on top of that and you’ve got paperwork upon paperwork. We know you have much better things to do with your busy workday!

Perhaps you have an eligibility verification process down to a science in your office. We applaud you if you do, but unfortunately there could still be pitfalls. Patient eligibility can change easily depending on possible employment termination of the patient or primary insured, unpaid premiums and nuances in a patient’s insurance coverage.

Eligibility checking is the single most effective way of preventing insurance claim denials, and subsequently preventing revenue loss. Check the patient’s eligibility, his or her deductible, and you’ve lowered the chances of a hit on your cash flow and profitability.

ClinicSpectrum’s Eligibility service is thorough, efficient and accurate. Plug and play!

We first retrieve a list of scheduled appointments and verify insurance coverage for patients 48 to 72 hours in advance of a scheduled visit.  Is that a sigh of relief we hear at the mention of eligibility verification in ADVANCE of a patient visit?

Once verification is complete, coverage details are put directly into the appointment scheduler for the office staff’s notification. You get what you need, where you need it, when you need it. We don’t think it could be any simpler!

ClinicSpectrum covers all the bases for you. We gather eligibility information through multiple avenues to get the job done, including:

  • Online – Using various Insurance company websites and internet payer portals we check patient coverage.
  • Automated Voice System (IVR) – By calling Insurance companies directly an interactive voice response system will give the eligibility status.
  • Insurance Company Representative Call – If necessary, calling an Insurance company representative will give us a more detailed benefits summary for certain payers when not available from either websites or automated phone systems.

The healthcare landscape is changing – it’s just reality! The landscape is especially shifting when it comes to patient billing with increased deductibles. Practices and billing companies can struggle to collect owed revenues just because of patient eligibility misinformation in some cases. We know there is a better way.

You have so much on your plate just to keep business running smoothly, keeping patients happy and healthy, and getting money in the door. Let us help you with patient eligibility verification today!


Eligibility Checking Part 1: Determining Patient Financial Responsibility

Eligibility Checking Part 2: Taking a Proactive Approach

How Does a Practice Deal with All These High Deductible Plans?

Workflow Interview: Vishal Gandhi of ClinicSpectrum, Booth #870 at HFMA

Patient Eligibility Verification Interview: Vishal Gandhi of ClinicSpectrum, Booth #301 at HBMA

The Eligibility Verification Time Suck

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