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HIE Staying Power: Eligibility Verification and Checking

Mount Rushmore, Rock music, Baseball and Apple Pie.

No, it’s not a recipe for a summer road trip; it’s a list of things that have staying power. Though the facade of Mount Rushmore may change over the years because of environmental conditions, it has been around for many years and will be for years to come. Rock music may get harder and less original, but it’s still a basic of the music scene. As for baseball and apple pie, while other sports may occasional eclipse it in popularity from time to time, stories of fathers and sons – and daughters! – bonding over nine innings of strategy and scorekeeping are numerous and legendary.

As discussed in one of our previous posts, an integral part of a successful HIE is working to ensure that it is sustainable long-term. Part of this success involves providing services that reduce existing costs along with services that offer administrative transaction cost savings, thereby balancing the cost of other  services such as clinical data exchange. A service we consider to be high in value is that of eligibility verification or checking.

A properly designed eligibility verification solution allows an HIE to quickly and effectively connect healthcare providers and health plans in real-time for the exchange of eligibility and benefits data. This eliminates the need to verify patient eligibility through multiple steps, from faxes and phone calls to less efficient paper-based processes. For payers, such a solution renders the ability to communicate patient-specific pre-authorization or eligibility to respond to various patient and provider queries. Also, eligibility verification can provide access to transactions like claim status checks and others. The ability of providers to access this information from one central place, the HIE, instead of multiple payer sites, saves the providers time and money.

A significant benefit of an eligibility verification or checking solution is its ability to lower administration costs for an HIE. By streamlining assorted transactions, the solution reduces rework, provides immediate and current patient data and results in a higher level of accuracy. In the area of patient medication safety, eligibility verification coupled with the reconciliation of prescribed medication and generation of electronic prescriptions can improve patient medication compliance and, most importantly, reduce prescription errors.

Security is a concern in any technology solution, a high quality eligibility verification solution allows for the appropriate exchange of various types of data while insuring the privacy for all those involved in an HIE. Today’s technologies are able to successfully accomplish this level of security at a much lower initial cost than was previously possible. In addition to the privacy, a well-built eligibility verification solution is by far more reliable that using any paper-based solution.

Advances in eligibility verification and checking put eligibility and benefit information instantly at the fingertips of those who require it in an HIE. Therefore, by implementing such a select service in the early stages of an HIE, a major step toward its sustainability is achieved. Incorporating such an integral solution at this stage also gives those involved a single point of connectivity to access necessary data. Just like with Mount Rushmore, rock music and baseball and apple pie, a successful eligibility verification solution should indeed do a large part to result in the necessary staying power for an HIE.