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Eligibility & Benefits — Real-Time Checks and Exceptions
Standardized checks, exception lanes, and clear scripts reduced downstream denials and escalations.
Context
- Eligibility/benefits checks varied by clinic; manual portals and inconsistent documentation.
- Downstream denials and patient responsibility disputes increased work for billing and front desk.
- No clear exception lane or same-day resolution discipline.
Approach
- Real-time eligibility where available; fallbacks with documented evidence screenshots.
- Exception queue with same-day resolution target and ownership matrix.
- Updated estimate macros for patient responsibility; script prompts for front desk.
- Definition locks for front-end dashboard tiles to stop drift.
- Dashboards for exception TAT, denial mix (eligibility-related), and escalation volume.
Measured Results
- Front-end exception same-day TAT 92%.
- Eligibility-related denials −18%.
- Patient billing escalations −21%.
- Documentation completeness improved across clinics.
Lessons Learned
- Use APIs where possible, but make screenshots a rule when you can’t.
- Same-day exceptions require owners and clocks—not just notes.
- Update estimate scripts alongside eligibility changes to avoid surprises.
- Lock definitions for tiles or front-end metrics will drift.
Cleaner front-end, fewer denials
We’ll standardize checks, scripts, and exception lanes across clinics.
