Is It Time to Automate Your Eligibility Workflow?

Manual eligibility verification checks are cumbersome and time-consuming. As your practice grows, what works at low volume (like a few phone calls per day plus some quick checks) becomes a bottleneck. Your front desk starts making "quick calls" to insurers that stretch into 45-minute holds. Staff spend mornings on hold, and verification backlogs spill into the next day. 

Many practices try to patch over the problem with overtime or additional hires, or offshore solutions. But the relief is only temporary before you start seeing the same problems resurface. Here are four specific patterns that signal you've hit the tipping point where it’s time to consider automating.

Denials climb despite good process. 41% of providers now report denial rates above 10%, up from 30% three years ago. Many of these are practices running tight operations: checking eligibility at registration, following up on questionable cases, double-checking before submission. When your team executes well and results still deteriorate, you've outgrown your current process.

Senior staff get stuck on low-value work. Your most experienced billers shouldn't be playing phone tag with insurers—but that's exactly what happens when verification breaks down. The people who know how to navigate tricky Medicare secondary payer situations or untangle modifier disputes are stuck on hold with Cigna instead. Physicians and their staff spend an average of 13 hours per week on prior authorization tasks alone—much of it performed by people whose expertise would be better used elsewhere.

Clearinghouse data doesn't answer the right questions. Pages of raw coverage data arrive, but the details that actually determine whether you'll get paid are buried in catch-all comment fields. A dermatology practice needs prior auth requirements for biologics; an orthopedic surgeon needs surgical benefit limits. Instead, everyone gets the same generic dump. Prior authorizations themselves have increased more than 40% since 2020, with layered deductibles, specialty tiers, and procedure-specific requirements adding complexity.

Coverage changes happen without warning. Your patient roster looks stable, but insurance coverage shifts constantly beneath the surface. This could be from job changes, open enrollment switches, or lapsed premiums—all events that you're rarely updated about ahead of time. Claims come back denied weeks after you've already delivered care, leaving you to write off the loss or have an uncomfortable conversation with someone who thought they were covered.

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What Modern Eligibility Looks Like

Purpose-built platforms can verify coverage with just a name, date of birth, and zip code. No more hunting for insurance cards or deciphering blurry photos. Smart workflows can flag high-risk patients before appointments, not after denials.

When it works well, eligibility verification becomes invisible infrastructure - running in the background while your staff focuses on patient care instead of daily fires.

If two or more of these patterns sound familiar, you've likely crossed the point where manual verification can keep up. Practices spending more than 15 hours weekly on verification tasks typically see ROI within 90 days of switching to automated systems.

Teams like Hopscotch saved 25 hours per week on eligibility verification after automating the process with Nirvana. Others, such as SonderMind, saved 64 hours per week while cutting benefit verification failures in half. By perfecting verification upfront, teams like Geode were able to flag 10,000 eligibility problems that would have otherwise resulted in claim denials.

These organizations are seeing immediate, meaningful improvements in team efficiency and denial rates simply by using Nirvana’s eligibility automation tools. Read more about how other teams are using Nirvana–and get your team set up today.