A wrongly denied insurance claim is a double-whammy. First, and most importantly, it can cause a delay in a patient’s treatment (and as a result, delayed revenue for the provider). But it also results in increased costs associated with re-submitting a claim. And unfortunately, benefit verification errors, which lead to such denials, aren’t uncommon.

Those errors add up. In fact, multiple studies have shown that administrative expenses – including benefit verification – account for up to 25% of total US healthcare expenditure, which has ballooned into the trillions. But why is benefit verification riddled with errors, anyway? And what can be done about it? 

We’ll explore answers to both questions below – and dive into how benefit verification automation can help.

Why mistakes in benefit verification are common: Human error

Benefit verification is complex, with multiple steps and types of information that needs to be accurately recorded in order to confirm patient coverage. This means that there are a number of reasons benefit verification errors are common – but most of them involve humans being, well, human.

Some of the most frequent errors include:

Incorrect information

Even a minor typo – missing one letter in a patient’s name, getting one digit wrong in their birthdate, mistyping a policy group number – can lead to a claim denial or delay. Errors can occur when copy and pasting data between systems or even just misreading a date while on a call. Unfortunately, even the most cautious, careful human is still human, and humans make errors. If any of this information is incorrect, it could cause problems with the verification process.

Mid-task interruption

Speaking of being human, errors like those above are more likely to occur when the person responsible for collecting the information is interrupted mid-task. In a busy back office, the likelihood of such interruption is high – a medical assistant at a surgery center might be on a call with a payor while simultaneously greeting patients as they enter the office.  This kind of interruption is especially prevalent during times like January, when benefit reverification needs pile up.

Asking the wrong questions

Issues can arise when a provider’s office calls a payor to confirm patient coverage but asks the wrong questions or leaves out key questions – for example, neglecting to ask about a secondary insurance policy or not pushing back when a payor agent provides information that an experienced caller would know is incorrect.

No healthcare background

Often, call centers that handle benefit verification do not require staff to have a deep healthcare background – this expertise is frequently reserved for those who handle prior authorization, claims, and medical coding. A lack of healthcare understanding can cause confusion during benefit verification calls, leading a caller not to ask the right questions, which in turn would lead to incorrect or insufficiently detailed information.

Primary and secondary coverage confusion

As mentioned above, some patients have coverage through two insurances. When this is the case, one insurance is considered primary and the other secondary. A patient enrolled in multiple insurances must self-report this information – but many don’t realize this, or aren’t aware of its importance. Unfortunately, this means agents might be unaware of secondary insurance and provide incomplete data. Even further, depending on the mode of administration, specialty drugs may be covered by a health plan as a medical benefit, pharmacy benefit, or both.

Coding errors

CPT codes are updated annually, which means frequent change to the way patient care is documented. Getting a CPT code wrong, or getting any associated information like a CPT exclusion wrong, can lead to a claim denial.

How to improve benefit verification accuracy

Automation of benefit verification tasks that happen off the computer, such as on the phone, is one way healthcare providers of all kinds can improve the process and reduce errors. But the truth is, a combination of benefit verification automation and human work can often lead to the optimal outcome.

At Infinitus, we have automated the benefit verification process by leveraging the power of AI – and our customers receive more accurate benefit verification data, faster. But it isn’t always just Eva, the Infinitus AI digital assistant, that’s ensuring benefit verification calls are completed quickly and correctly. 

For example, if an insurance agent provides incorrect information, and continues to do so even after receiving pushback from our digital assistant, a human Infinitus AI-trainer can jump in to ensure our customers receive accurate data. AI, with human oversight when necessary, helps reduce the common benefit verification errors listed above.

Interested in learning more? Contact us to discover whether Infinitus can help streamline the benefit verification process for you.