Is It Time to Automate Your Eligibility Workflow with Nirvana?

Every healthcare provider has been there: Pouring resources into analyzing clearinghouse data and building custom processing solutions, yet still facing bottlenecks that consume valuable hours from their teams’ workday.

These hurdles are not just incredibly time-consuming — they also lead to costly claim denials and canceled appointments. Juggling this operational burden with delivering exceptional care leaves many decision-makers wondering when they should move beyond patchwork eligibility fixes.

An off-the-shelf eligibility platform can streamline your verification and free up more time for patient care. Here's how to tell if your practice is ready to make the investment.

Four Signs You Need a Dedicated Eligibility Platform

If your practice has lower patient volumes, smaller payer networks, or a limited scope of treatment, you might have the bandwidth to verify benefits using general clearinghouse data.

But for most clinics, balancing day-to-day responsibilities with manual benefit verification quickly becomes unsustainable. Here are four red flags that you've reached that tipping point.

1. Denial Rates Exceeding 5%

Healthcare leaders identify eligibility and registration errors as the top reason for initial claim denials, with 50% reporting more rejections in 2023 compared to the previous year. Denial rates usually become unsustainable around the 10% industry benchmark — also known as the "danger zone." So once they surpass 5%, you need to act fast to prevent your practice from reaching this tipping point.

When patient ineligibility comes to light, providers often postpone — or cancel — a substantial number of upcoming appointments. These disruptions in treatment can drive patients to other providers that accept their insurance, directly impacting your ability to provide reliable care and secure more revenue.

In the meantime, your team is preoccupied as they track down the root cause of each rejection. And with each claim resubmission costing your practice between $25 and $100, reworking these mounting claims quickly erodes your bottom line.

While a clearinghouse might provide some helpful coverage information, it rarely delivers all the details you need to verify coverage easily and submit accurate claims:

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• Convoluted coverage data: Clearinghouses bury tons of useful information into lengthy, multi-page responses that are complex, inconsistent, and hard to follow. As a result, accurate interpretation is notoriously difficult for billing and admin teams, and nuanced details — like tiered copay structures and deductible-dependent copays — often slip through the cracks.
  
• Inaccurate capture of detailed insurance plans: Insurance plans are growing more intricate to align with new regulations, healthcare dynamics, and market conditions. However, clearinghouses often cram these updates into catch-all "comments" sections due to their predefined data communication structure. Because these eligibility solutions dominate the market, they have little incentive to fix this limitation — leaving providers digging for essential information necessary for accurate estimates.

2. Benefit Verification Takes Too Much of Your Staff's Time

When you spend more time verifying benefits than serving patients, hanging onto manual processes becomes counterproductive. And it's not just the patient experience that takes a hit — your practice health also declines.

Most healthcare teams spend hours tracking down data for claims — navigating the labyrinth of insurance portals, waiting on hold with payers' call centers, and calling patients to patch incomplete intake records. As your practice grows, this time sink only intensifies — and so does your team's potential for administrative burnout.

While clearinghouses and custom solutions might alleviate some of this burden, they often substitute one set of problems for another:

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• Hampered productivity due to context-switching across platforms: Healthcare teams often have to split their focus across multiple platforms in day-to-day work. In 2024, 59% of practices used at least two solutions just to gather accurate patient information for claim submission. This inefficient workflow slows them down, increases the risk of manual errors, and potentially diminishes the quality of care. Clearinghouses are yet another solution that doesn't integrate with existing systems, further disrupting your processes.
  
• Increased manual analysis due to limited monitoring functionality: Clearinghouse systems lack the real-time monitoring capabilities you need to track patient eligibility at all times. This means that if a patient you verified last week changed their insurance plan without informing you, you would still operate on outdated information. As a result, your team spends countless hours verifying and updating information.

3. Patient Satisfaction Scores are Dropping

According to a recent survey, 96% of patients want an accurate, upfront estimate of treatment costs. Even more worrisome, 43% of patients will cancel an appointment without accurate cost data. While patient satisfaction depends on accurate benefit data, outdated verification workflows make it nearly impossible to deliver cost transparency, limiting their access to care.

The downsides of unreliable coverage data don’t stop at patient intake. Without the right information, your team might administer care that's not reimbursable. In turn, your patients may be billed unexpected out-of-pocket expenses, diminishing their confidence in your practice. And when satisfaction decreases, the ripple effects on your patient retention and revenue can be difficult to reverse.

Faulty solutions lead to poor results, ultimately driving down patient satisfaction.

4. Limited Development and Upkeep Resources

When clearinghouse data falls short, building a dedicated eligibility solution often seems like the logical next step for streamlining your verification process. But, developing your own solution in-house is complex and resource-intensive.

To generate accurate benefit data, you need a cutting-edge machine learning (ML) model. Training this technology to analyze over 100,000 unique health plans and surface reliable results takes years — and a dedicated engineering team. This process is simply impractical — it siphons considerable resources you could invest in growing your practice, all while drawing attention away from patient care.

Even if your practice has the time, technical team, and financial capital to engineer a model like this, data access alone isn’t enough. You also need:

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• An intuitive interface for higher efficiency: A user-friendly platform parses all complex insurance data and distills it into a clear benefit summary. These functionalities eliminate the need for manual interpretation, minimizing verification time and potential errors. If your patients need to access the software to share insurance details, a seamless user experience is even more critical. Friction at intake can lead up to 30% of patients to seek care with another provider.‍
• Up-to-date insurance data: ML model accuracy hinges on its ability to adapt to evolving insurance plans and policies. This adaptability requires a dedicated in-house team to regularly monitor industry changes and verify model output. Without this continuous data validation, your practice risks returning to square one — putting hours into collecting accurate benefit information.

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Nirvana Transforms Healthcare Operations with Instant Eligibility Verification

Nirvana combines AI-enabled, real-time verification technology with the quality assurance of dedicated billing experts to bridge the gap between accurate patient data and efficient healthcare workflows. This way, we keep your focus where it belongs — on patient care.

We deliver instant coverage data with 94% accuracy, capturing critical benefit details and insurance plan updates that traditional clearinghouse responses might miss. This real-time verification protects practices from costly claim denials, extra administrative workload, and unnecessary pauses in treatment.

Behind this precision is Nirvana's proprietary AI technology — the only one in the industry tailored to interpret the unique insurance nuances across diverse healthcare specialties.

Over four years and tens of millions of patient appointments, we've trained our ML model to process complex coverage details from 180,000+ healthcare plans — including data buried in clearinghouses' catch-all "comments" sections. As our in-house team of billing advisors consistently verify output quality, our technology extracts, analyzes, and presents benefit and copay data in an intuitive, actionable format that's always up-to-date.

This wealth of knowledge enables Nirvana to spot patterns across millions of eligibility checks. Plus, Nirvana's AI continuously learns from provider input, helping you surface the exact information you need — faster.

While clearinghouses take patient information and leave you with a cabinet of coverage details to sort through, Nirvana gives you the exact file you need. And we do this at every touchpoint through powerful features like:

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• Discover: Unlike manual verification methods and clearinghouses, Nirvana's Discover intake tool delivers insurance data using only the patient's name, date of birth, and zip code. This approach eliminates time-consuming back-and-forths between patients and your team, boosting appointment conversion rates by 30%.
• Coverage API: Nirvana's Coverage API integrates accurate benefit data into your EHR to minimize context-switching between platforms. Through this connection (and a few easy-to-create custom rules), your team can set up automatic insurance checks based on your calendar and specific payer mix.
  
• OneVerify: Centralizing all verification operations in Nirvana's eligibility management platform increases team productivity by up to 300%. OneVerify presents complex insurance data in an intuitive format — regardless of payers' coding conventions. Even better? Smart workflow recommendations flag patients at risk of denial, keeping your staff one step ahead of coverage lapses.

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With Nirvana, one of the largest behavioral health organizations in the US turned insurance verification from a liability into an asset. Since connecting our platform to their EHR, their team has more than doubled biller efficiency while preventing revenue loss from 21,000+ claims at risk of denial. These improvements allow them to scale their practice without additional overhead.

Ready to transform your practice's performance and patient experience? Book a demo today!