ZapEHR’s Revenue Cycle Management Service

Insurance Eligibility Verification

One of the greatest challenges faced by providers and patients alike is the cumbersome process of insurance eligibility verification. From endless phone calls to outdated fax machines, the current landscape is fraught with delays, inefficiencies, and frustration at every turn. Providers struggle with manual data entry, delayed responses from insurance companies, and billing inaccuracies, while patients endure long wait times, uncertainty about coverage, and administrative hassles.

ZapEHR, a leading platform for building API-first health-tech applications, is proud to introduce a solution to put an end to those frustrations–our newest service: Revenue Cycle Management. And part of our comprehensive RCM suite, we’re excited to introduce real-time insurance eligibility verification, now available live and out of beta. We’ll provide insights into our new insurance eligibility service, its functionalities, and how it can benefit your EHR, health-tech applications, and clinical organizations.

Real-Time Insurance Eligibility Check:

Our insurance eligibility service allows health tech builders to seamlessly integrate real-time insurance eligibility checks into their applications. With just a few API calls, healthcare providers can submit a patient's insurance information and receive detailed coverage and benefits information in response.

How It Works:

Our real-time insurance eligibility service includes HIPAA-compliant solutions for prior authorization checks, allowing healthcare providers to quickly determine coverage for medical services and streamline the approval process.

Developers can initiate an eligibility check request using either the Typescript SDK or the API. By providing essential details such as payer ID, provider information, and patient's subscriber details, developers can trigger an eligibility check and receive a comprehensive response.

Test Mode:

During development, developers can enable "test mode" to simulate eligibility check responses without sending requests to the payer. This feature allows developers to test various scenarios and workflows, ensuring seamless integration and robust error handling.

Integration with FHIR:

Our insurance eligibility service seamlessly integrates with the Fast Healthcare Interoperability Resources (FHIR) standard, ensuring interoperability and smooth data exchange. When an eligibility check request is submitted, ZapEHR automatically creates FHIR resources, capturing essential payer data and patient data, including CoverageEligibilityRequest and CoverageEligibilityResponse. These resources are securely stored in the project's FHIR store, enabling access to the patient record and utilize them for further processing.

The insurance eligibility service provides developers with key information about a patient's coverage, copay, coverage dates, and benefits. By leveraging this data, developers can enhance their clinical workflows by:

• Streamlining patient registration processes by verifying insurance coverage upfront.
• Automating billing and claims processes by ensuring services are covered under the patient's insurance plan.
• Improving patient experience by providing accurate cost estimates and reducing financial surprises.

Why it’s better than the traditional method

Traditionally, verifying patient insurance eligibility involves manual processes and reliance on outdated information, leading to inefficiencies, missing data, and errors in revenue cycle management. Healthcare providers often face significant challenges such as:

Manual Data Entry: In the traditional model, front desk staff manually input patient insurance details into the system and wait for responses from insurance companies. This manual process is time-consuming and prone to errors, resulting in delays and inaccuracies in scheduling appointments and processing claims.

Delayed Responses: Waiting for insurance eligibility verification responses from insurance companies can cause delays in patient care and revenue collection. With the traditional model, healthcare providers may experience prolonged wait times for eligibility information, leading to frustrated patients and administrative bottlenecks.

According to a study conducted by the Medical Group Management Association (MGMA), healthcare providers spend an average of 20 hours per week on administrative tasks related to insurance eligibility verification using traditional methods such as phone calls and manual data entry. It is estimated that ZapEHR’s automated and instant solution can potentially reduce the time dedicated to insurance eligibility tasks by 80%. 

Billing Inaccuracies: Inaccurate, missing information, or outdated insurance information can result in billing errors and claim rejections, impacting revenue streams and patient satisfaction. Without real-time access to updated coverage and benefits information, healthcare providers may struggle to ensure accurate billing and timely reimbursement.

Patient Frustration: Patients often experience frustration when faced with delays in scheduling appointments or uncertainty about their insurance coverage. The traditional model of insurance eligibility verification contributes to patient dissatisfaction and can negatively impact the overall patient experience.

In contrast, ZapEHR's real-time insurance eligibility check service offers an efficient and simple solution to these challenges. By leveraging API first technology and integration with insurance databases, ZapEHR provides:

Automation: ZapEHR automates the insurance eligibility verification process, eliminating the need for manual data entry and reducing administrative overhead. This automation streamlines workflows and allows healthcare providers to focus more on patient care.

Instant Responses: With ZapEHR's service, healthcare providers receive real-time eligibility verification responses within seconds, enabling faster decision-making and improved patient access to care. This instant access to updated coverage information enhances efficiency and patient satisfaction.

Accuracy: By accessing up-to-date coverage and benefits information directly from insurance databases, ZapEHR ensures accuracy in eligibility verification and billing processes. This reduces the likelihood of billing errors and claim rejections, optimizing revenue cycle management for healthcare providers.

Enhanced Patient Experience: By offering quick and accurate insurance eligibility verification, ZapEHR enhances the overall patient experience. Patients benefit from shorter wait times, increased transparency regarding their coverage, and reduced frustration when scheduling appointments or undergoing medical procedures.

ZapEHR's real-time insurance eligibility service empowers health tech developers to build innovative applications that streamline revenue cycle management and enhance patient care. By integrating our service into their EHR and health-tech applications, developers can ensure seamless insurance eligibility checks and deliver exceptional experiences for both healthcare providers and patients. 

Explore our API documentation and API Reference to learn more about integrating to unlock the full potential of real-time insurance eligibility checks in your applications.

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What’s next on the product roadmap? 

Claims submission and claims status.

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