The right eligibility data management solution

Last month, we identified how eligibility data errors may be undermining your health plan’s payment integrity efforts. Certainly there are many factors to consider when correcting erroneous eligibility data, but the bottom line is this: in order to maximize payment integrity outcomes, health plans need a single, accurate, trusted source of eligibility data.

It sounds simple enough, but, like many health plans, you may be left wondering how to begin addressing this issue.  Although you may already have a team of talented, hard-working individuals, navigating the complex world of eligibility data can be much easier with an experienced partner and a proven service solution.

Let’s take a look at some of the critical components an eligibility data management service solution must have to help maximize recoveries and drive ongoing cost avoidance.

Comprehensive data mining

Accurate eligibility determinations require the seamless integration of data from multiple resources, along with powerful data mining capabilities to identify potential issues. This means your vendor will help you proactively identify more instances of other coverage by utilizing every available, relevant data resource.

  • Examine your health plan’s commercial coverage claims and eligibility information
  • Validate leads, determine primacy, and update eligibility for all other data sources including data-match vendors, Section 111 reporting, MSP files, and provider bills

A proven process

The right solution leverages a proven process to identify potential cases, investigate the appropriate data sources, and correctly apply the NAIC rules to determine primacy. The process should be built on transparency between you and your vendor so that you have insight into each step and a clear understanding of the expected and actual results.

Superior analytics

The right solution relies heavily on advanced analytics to determine primacy and make eligibility decisions. However, the analytics engine needs to be flexible enough to accommodate your plan’s specific data sets and needs. Your vendor should work with you to understand your current data, identify the largest opportunities, and create a strategy and approach that address your plan’s specific priorities.

Transparent reporting

The right solution isn’t a black box. You and your team should have full visibility into your vendor’s performance. A standard report package should include eligibility update and inventory reports that allow you to see progress on a weekly and monthly basis. But, you should also have the ability to customize report content and frequency to meet your plan’s specific needs.

Dedicated partnership

The right solution isn’t from a vendor at all, it’s from a partner. Align your plan with a partner that is dedicated to improving your busi­ness processes and your bottom line. Their team should complement yours in their knowledge, approach, and experience. And their results should be proven, referenceable, and demonstrable.

Addressing eligibility data management can seem like an overwhelming or impossible task among all of your other competing priorities. However, fixing these data errors can eliminate downstream impacts to your payment integrity programs that are likely costing your plan millions of dollars. Next month, we’ll show you just how big those impacts can be in our blog post that will highlight the results of implementing a service solution like the one we’ve described above.


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Paul VostersThe right eligibility data management solution