How to streamline verification of benefits workflows

Verification of benefits (VOB) is the process of confirming a patient's insurance coverage, including eligibility, covered services, copayments, deductibles, and authorization requirements before treatment begins. However, traditional VOB workflows often have inefficiencies, manual data entry, and communication delays that can frustrate staff and delay patient care.

As noted in the research article titled, "Identifying Opportunities for Workflow Automation in Health Care: Lessons Learned from Other Industries", automation has been "successfully implemented in other industries to improve quality, productivity, efficiency, timeliness, effectiveness, and operational safety, as well as to reduce costs and deliver better value to customers." Here's how healthcare organizations can transform their verification of benefits workflows into a competitive advantage.

Understanding the current workflow challenges

Common challenges include manual phone calls to insurance companies, inconsistent documentation practices, lack of real-time visibility into verification status, difficulty tracking which verifications are complete or pending, and frequent errors in recording coverage details that lead to claim denials. Eva Hibnick from One Body, which provides an AI verification of benefits tool to clinics, says “it’s always important for clinic owners to evaluate how long verifications are currently taking staff and to see what tools are out there to make it more efficient for staff to accomplish the workflows they do.”

Over time these challenges create problems that affect everything from scheduling efficiency to cash flow. According to the Centers for Medicare & Medicaid Services (CMS) document "Health Plan Eligibility and Benefits Transaction Basics," standardization is needed because "widespread use of Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) adopted transactions—where everyone uses the same language, format, and code sets—can lead to substantial savings across the health care industry."

As noted in Process mapping in healthcare: a systematic review, "quality and safety failures in healthcare are attributable more to systems and processes than to human errors." The first step toward improvement is conducting an assessment of the current workflow to identify specific inefficiencies. The research article emphasizes that workflows most suitable for automation include those characterized by "manual data entry, high frequency and/or repetition, clearly defined independent and dependent variables for modeling, [and] clear roles and responsibilities."

Implement automated verification tools

Automated verification software can check insurance eligibility and benefits in real-time. These tools integrate with insurance payer systems to retrieve accurate, up-to-date information about coverage, deductibles, copays, and authorization requirements.

As CMS notes, "when electronic transactions are used effectively in health care, they: Increase efficiencies in operations, Improve the quality and accuracy of information, Reduce the overall costs to the health care system." These automated systems use standardized transactions that allow for seamless communication between providers and payers.

When selecting an automated VOB solution, look for features like real-time eligibility checking across multiple payers, integration with your practice management or EHR system, automated alerts for missing or expired insurance information, and detailed coverage summaries that are easy to understand and share. 

Establish clear automation goals

According to the article, Empowering Healthcare: A Comprehensive Guide to Implementing a Robust Medical Information System, "the importance of identifying clear goals for automation and gaining consensus about them among stakeholders cuts across industries and workflows." The goals might include reducing average verification time from 25 minutes to 5 minutes, completing 100% of verifications at least 48 hours before appointments, decreasing claim denials related to eligibility issues by 50%, or improving staff satisfaction by reducing repetitive manual tasks.

According to the research article, "automation goals may not be met if a clear set of goals is not identified and stakeholders impacted by automation are not engaged." Take time to gather input from the verification team, billing staff, and front office personnel to ensure that automation goals align with real operational needs.

Standardize the verification process

Develop standardized protocols that every team member follows when conducting verifications. The systematic review emphasizes that process mapping "is a tool to break-down the complexity characterizing healthcare, by providing improvement teams with a structured picture of complex processes, using information from process stakeholders holding different roles and perspectives." 

Create a checklist of information that must be gathered for every patient. According to CMS guidelines, eligibility operating rules require health plans to provide specific financial information in real time, including "deductibles, copays, coinsurance, and in/out of network variances" as well as "coverage information for specific service types." A standardized checklist should capture all of this information, including:

• Active coverage dates
• Deductible amounts and how much has been met
• Out-of-pocket maximums
• Copayment and coinsurance requirements
• Prior authorization requirements
• Covered services and any exclusions

Document these standards in a clear, accessible procedure manual and provide training to ensure everyone understands and follows the same process. Standardization reduces errors, makes it easier to train new staff, and ensures nothing falls through the cracks. The research article highlights that successful implementation requires "obtaining their input as roles and responsibilities are documented, training them, eliciting their feedback during implementation of automated workflows, and proactively addressing concerns." 

Verify benefits earlier in the patient journey

Early verification provides several advantages, including more time to resolve any coverage issues before the appointment, ability to inform patients of their financial responsibility in advance, opportunity to obtain prior authorizations without delaying care, and reduced risk of last-minute cancellations due to coverage surprises.

Proactive verification also improves the patient experience by eliminating uncertainty and allowing patients to make informed decisions about their care.

Create a centralized verification team

Rather than having multiple staff members handling verifications sporadically throughout the day, consider creating a dedicated verification team or assigning specific team members to focus exclusively on VOB during designated hours. According to the systematic review, "process mapping (PM) has the potential to support QI projects in healthcare by engaging stakeholders to create a shared understanding of the systems they are trying to change." Centralization creates expertise and efficiency as team members become skilled at navigating insurance systems and resolving coverage questions. 

The research article notes that successful automation requires attention to "people aspects," including "attaining leadership support and ensuring that staff throughout the organization is aware of the institutional commitment to automation." This approach works well for larger practices or facilities with high patient volumes, though even smaller operations can benefit from designating specific "verification hours" when one person focuses exclusively on this task.

Leverage digital communication channels

Many insurance companies now offer online portals, mobile apps, and API integrations that provide faster access to eligibility and benefits information. 

The regulatory framework supporting these digital tools has been strengthened over time. CMS notes that "eligibility operating rules require health plans to respond in real time to providers' eligibility inquiries with a patient's financial information" This mandate, which has been in effect since January 1, 2013, ensures that providers can expect timely responses when using electronic verification methods.

Track metrics and continuously improve

Establish key performance indicators (KPIs) for your VOB process and track them regularly. Important metrics include average time to complete verification, percentage of verifications completed before appointments, claim denial rate related to eligibility or coverage issues, and patient satisfaction scores related to financial communication.

The research article emphasizes that "as workflow automation is implemented and used, ongoing monitoring and analysis are needed." Furthermore, "one common theme found in the literature was the need to continue monitoring and reviewing automated workflows. This involves returning to the original automation goals and reviewing progress."

Review these metrics monthly and look for trends or areas needing improvement. Engage verification teams in problem-solving discussions and solicit their input on process enhancements. The systematic review highlights that effective process improvement "was reported to be particularly useful to engage and motivate project stakeholders in designing and implementing change." 

FAQs

What’s the difference between verification of benefits and insurance eligibility checks?

Verification of benefits includes eligibility checks but goes further to confirm coverage details like deductibles, copays, and authorization requirements.

How often should healthcare organizations review their VOB process?

At least quarterly reviews are recommended to identify emerging inefficiencies and ensure automation tools remain effective.

Can small practices afford automated verification systems?

Yes, many vendors offer scalable, cloud-based solutions that fit smaller practices’ budgets and needs.

What risks come with automating the VOB process?

Poor configuration or lack of staff training can lead to inaccurate data exchange or missed updates.

How does VOB affect patient satisfaction?

Accurate and timely verification reduces billing surprises and improves patients’ trust in their providers.