Eligibility data management: Fixing payment integrity at the source

With all of the demands on your team, your time, and your resources, eligibility data management may not be your first priority. After all, you have to focus on maximizing recoveries and avoiding costs. Which is exactly why you should consider evaluating your current eligibility data management structure and processes. In our experience with over 15 health plans, eligibility data issues are the root cause of between 20% and 30% of payment integrity costs.

Claim recovery

Accurately determining which claims have been paid incorrectly due to eligibility data errors for your plan can streamline your recovery efforts to ensure maximum efficiency and results. We estimate that 20% of a plan’s membership will have other insurance and of that 20%, the other insurance will be primary 17.5% of the time. For a 200,000 member plan, this represents nearly $5.4 million in incorrectly paid claims. We believe with the right solutions and expertise, health plans can expect to recover a significant portion of those claims.

Cost avoidance

Of course, if your eligibility data is accurate and trusted, your plan won’t have to worry about recovering dollars from incorrectly paid claims. You will be able to avoid paying them altogether by paying claims correctly the first time. For that same 200,000 member plan, our experience indicates the savings by avoiding those incorrect payments through the use of accurate and trusted eligibility data is over $13.4 million.

Administrative efficiency

In addition to the recoveries and restorations that go directly to your bottom line, you should also consider the time and expense associated with rebilling or recovering inaccurate claims payments. Identifying, processing, recovering, and rebilling incorrectly paid claims has a significant cost in terms of time, money, and personnel. By eliminating the need to rebill, you save valuable time and energy that can be channeled toward other payment integrity initiatives.

Member satisfaction

In the increasingly competitive consumer driven health insurance marketplace, health plans are focusing on member satisfaction as a strategic priority, and accurate eligibility information is a critical component. Claims that are declined due to inaccurate or out-of-date eligibility data can lead to member abrasion, lost market share, and reduction in STAR ratings.  Eligibility data impacts more areas of a health plan than any other data set.  Eligibility data drives a diverse number of systems and processes include signup, enrollment, care provision, wellness, customer care, and even termination. All of these areas influence your member’s experience with your plan.

Provider relations

Claims denied due to eligibility issues can lead to provider abrasion, increased costs for rebilling, and can damage network affiliations. Provider operations and, more importantly, their revenue cycle management, are largely dependent on accurate eligibility data. Reductions in administrative expense and increases in financial accuracy are passed on to providers, and can deliver substantial benefits through improved provider relations while reducing any potential negative impacts between members and providers .

The Discovery Health Partners team has seen first-hand how creating a single, trusted source of accurate eligibility data has helped health plans improve in each of the above areas and has additional benefits across your health plan and the entire healthcare ecosystem. By leveraging multiple data sources and employing predictive data mining and analytics, we are able to verify and update eligibility status and make it available to claims adjudication systems and other downstream applications. To learn more about our solution and how it could impact your bottom line, visit our Eligibility Management resource page.


Paul VostersEligibility data management: Fixing payment integrity at the source