Building Trust Through Better Urgent Care Eligibility Verification

Key Takeaways

• Eligibility verification issues cause significant claim denials and create barriers to urgent care access, with patients worried about unexpected medical bills.
• Urgent care centers face unique real-time verification challenges, with multiple sources of errors and delays
• Modern automated verification systems and upcoming regulatory changes (e.g. implementing HL7 FHIR standards by 2026) will streamline eligibility checks and prior authorization processes.
• Organizations that prioritize efficient eligibility verification will see improved patient trust and reduced bad debt

Urgent care eligibility verification directly impacts cost transparency and patient trust. When patients seek urgent care services with conditions like broken bones or severe infections, they need immediate treatment - and they'll get it regardless of coverage status. What they deserve is immediate clarity on what that necessary care will cost them, not a surprise bill months later.

This challenge is amplified for the significant Medicaid population that relies on urgent care centers. With ongoing changes in government regulations and state-specific Medicaid requirements becoming increasingly complex, verification for these vulnerable patients has become even more critical to ensure access to care.

Recent industry data highlights the scope of this challenge. About 15% of all claims submitted to private payers are initially denied, with nearly half of providers identifying missing or inaccurate data as the primary cause of denials.

The Urgent Care Eligibility Workflow Challenge

Across the healthcare landscape, nearly three in four providers say claim denials increased between 2022 and 2024, with the majority originating during patient access processes including registration and eligibility verification. Meanwhile, urgent care centers face unique verification challenges compared to other healthcare settings. Unlike scheduled appointments where verification can occur days in advance, urgent care must process eligibility in real-time while patients wait. 

The urgent care verification workflow contains multiple critical checkpoints where errors commonly occur:

• Initial patient registration with insurance card capture - outdated or incorrect information
• Real-time eligibility inquiry to payer systems - connectivity failures or timeout issues
• Benefit verification including copays, deductibles, and coverage limits - misinterpretation of complex plans
• Prior authorization requirements for specific services - missed authorization needs
• Secondary insurance coordination when applicable - incorrect coordination of benefits

Each failure point compounds delays. For urgent care centers, these delays threaten their ability to maintain adequate staffing, keep doors open during extended hours, and continue serving those in need.

Patient Impact Beyond the Visit

The burden on patient care extends far beyond the initial visit. Urgent care centers increasingly serve as de facto primary care providers and referral sources. A patient with a broken arm needs immediate treatment but also requires referrals for physical therapy, orthopedic follow-up, and ongoing care coordination. Verification failures at the urgent care level cascade through the entire care journey.

Specific urgent care scenarios negatively impacting patients include:

• Outdated insurance information causing surprise bills weeks or months after visits
• Inability to obtain clear, accurate cost estimates before agreeing to treatment
• Confusion about urgent versus emergency benefits leaving patients unsure about total costs
• Extended wait times while staff manually verify coverage after business hours
• Repeated information requests due to disconnected systems between urgent care and referral providers

Practice Impact 

Verification friction directly impedes practice growth and patient retention. Consider a large provider serving approximately 65,000 patients today with ambitious plans to double their patient base. One of the major hurdles they face in achieving this goal is the inability to efficiently verify eligibility, particularly for the ongoing care services that urgent care patients are frequently referred to.

When an urgent care visit leads to ongoing care - such as physical therapy or behavioral health - patients encounter cascading verification challenges. Physical therapy requires authorization for multiple sessions, often with visit limits that vary by plan. Behavioral health benefits involve complex carve-outs, session caps, and specialized networks. Each referral triggers another round of verification delays, and each additional day increases the likelihood that patients abandon care entirely.

For practices, this verification friction creates a vicious cycle. Unable to quickly verify and onboard new patients, they cannot achieve the scale needed to invest in better systems. Staff spend hours on phone calls with payers instead of patient care. Growth stalls not because of clinical limitations, but because of administrative bottlenecks that could be automated.

Solutions and Best Practices

Accurate, real-time eligibility verification protects the patient-provider relationship. By providing upfront cost transparency, organizations give patients clear information about coverage before treatment, reduce anxiety about unexpected costs, and enable informed care decisions.

Multiple approaches can address verification challenges:

Automated Verification Systems: Modern platforms such as Nirvana integrate directly with payer databases, returning eligibility information in seconds while providing instant cost estimates to patients. These systems verify coverage across multiple payers simultaneously, flag prior authorization requirements, and provide transparent out-of-pocket costs before service delivery. (60% of medical group leaders report increased denial rates in 2024 compared to 2023, yet only 31% currently use automation or AI solutions).

Regulatory Improvements: New regulations incorporating HL7 FHIR standards will require health plans to return additional data including prior authorization details, tiered benefits, and maximum benefit information. Starting in 2026, Medicare Advantage and Medicaid plans must provide prior authorization decisions within 72 hours for urgent requests.

AI-Powered Staff Enablement: Rather than relying on manual checklists, AI tools can guide staff through complex verification scenarios, automatically flag high-risk claims, and suggest optimal billing codes. These tools learn from denial patterns to prevent future issues while freeing staff to focus on patient care rather than administrative tasks.

Patient Communication Tools: Clear cost estimate tools, automated insurance card capture systems, and patient portals for pre-registration improve data accuracy while reducing wait times.

Measuring Success and Continuous Improvement

Organizations implementing comprehensive eligibility verification should track patient-centered metrics:

• Patient wait times from arrival to treatment
• Patient satisfaction scores regarding billing transparency
• Time to provide accurate cost estimates
• First-call resolution rates for patient billing inquiries
• Percentage of patients inquiring about surprise bills post-visit
• Staff time freed for direct patient care versus administrative tasks

By improving on these metrics, urgent care centers remove barriers to care while building patient trust through transparency. When patients understand coverage before treatment begins, they make informed decisions without financial fear. For urgent care centers, investing in robust eligibility verification represents both operational necessity and commitment to patient-centered care.