Healthcare billing is getting more complex, and so is insurance scrutiny. One of the most common causes of claim denials? Lack of proper eligibility verification and prior authorization.

If you’re not checking patient benefits before rendering services or failing to obtain payer approvals in time, you’re risking unpaid claims and revenue loss. Here’s how you can fix that — and get paid faster.

What Is Eligibility Verification?

Eligibility Verification is the process of confirming a patient’s insurance coverage, active policy status, co-pays, deductibles, and benefits before services are provided.

Why it matters:
If you treat a patient without checking coverage, you risk delivering non-reimbursable services.

What Is Prior Authorization?

Prior Authorization (PA) means obtaining formal approval from the insurance provider before specific treatments, medications, or procedures.

Why it’s critical:
Many payers deny claims if prior approval is not documented — even if the service was medically necessary.

Top 5 Reasons You Must Prioritize These Processes

1. ✅ Reduces Claim Denials by 60%+

2. ✅ Improves Patient Experience (No surprise bills!)

3. ✅ Ensures Timely Reimbursement

4. ✅ Avoids Compliance Risks

5. ✅ Optimizes Front-End RCM Efficiency

Real-World Impact: Why Most Denials Are Preventable

According to CMS and MGMA reports, over 80% of claim denials are preventable — and eligibility & authorization issues are at the top of that list.

Without these checks:

• Providers deliver non-covered services unknowingly

• Claims get rejected or delayed

• Patient dissatisfaction rises