Top 10 Common Mistakes in Eligibility Verification and How to Avoid Them

Eligibility verification and prior authorization are foundational elements of a healthy revenue cycle. Yet many practices make small but costly errors that lead to claim denials, delays in care, and lost revenue. Avoiding these common mistakes can significantly improve operational efficiency and patient satisfaction.

1. Not Verifying Insurance at Every Visit Many providers verify insurance only during the first visit. However, insurance status can change, and failing to check coverage regularly may lead to denied claims.

2. Using Outdated Information Always use the most recent insurance cards and verify policy numbers, group IDs, and plan details.

3. Not Understanding Plan Limitations Failing to check service limitations, exclusions, or network restrictions can cause claim rejections or patient dissatisfaction.

4. Incomplete Data Entry Typos in the patient’s name, date of birth, or member ID can result in a mismatch with payer records.

5. Skipping Real-Time Eligibility Tools Manual checks are time-consuming and prone to error. Use automated tools to streamline the process.

6. Assuming Authorization Isn't Needed Even if a service seems routine, it might require prior authorization depending on the payer.

7. Not Documenting Authorization Details Keep records of authorization numbers, approval dates, and who provided the authorization.

8. Ignoring Secondary Insurance Always ask about secondary coverage to ensure complete payment and avoid balance billing.

9. Failing to Communicate with Patients Always inform patients about what is covered and what isn’t to prevent frustration.

10. Not Training Front Office Staff Staff must be equipped with the skills and tools to perform eligibility checks effectively.

Solutions to Avoid These Mistakes

• Use integrated eligibility tools in your EHR.

• Partner with reliable RCM providers.

• Establish clear SOPs for verification and authorization.

• Follow up proactively on pending authorizations.

A few small changes in your workflow can dramatically improve accuracy in eligibility verification and prior authorization, leading to better reimbursement rates and happier patients.