Why Eligibility Issues Compound as Organizations Scale

Eligibility verification consumes 16% of all administrative costs in medical billing. The amount of overhead grows with every new patient, creating complexity that adding more staff can't solve.

Eligibility verification takes 10 (or more) minutes per patient on average. Staff loop through calling payers, navigating phone systems, waiting on hold, and documenting results. When insurance changes mid-treatment or prior authorizations expire, that 10-minute estimate doubles or triples. Multiply the time spent by the number of patients your practice adds as it grows, and you can quickly see how this becomes a significant problem.

Multi-location practices face steeper challenges. Each site brings regional payer variations, local plan exclusions, state-specific coverage rules. For example, physical therapy covered in Denver gets excluded in Phoenix. Staff have to juggle verification volumes while mastering dozens of regional requirements.

More Claim Denials, Fewer Resources

Billing team members also contend with the rising rate of claim denials. Initial claim denials climbed to nearly 12% in 2024 - a 2.4 percentage point year-over-year increase. 41% of providers now face denial rates affecting at least one in ten claims, up from 30% in 2022. More than half of U.S. healthcare organizations report denial rates exceeding 10%. 

As a result, patients are impacted as they wait longer for treatment while authorization paperwork catches up. Having worked closely with provider teams managing this transition, we've seen eligibility verification transform from manageable daily task into the primary constraint on operational growth. Providers must manage complexity that wasn't designed to scale with their patient populations.

The workarounds live in team member's heads. If experienced staff eventually leave, they take years of payer-specific knowledge with them. They know which codes map to specific services, how to get through UnitedHealthcare's phone tree efficiently, and which Aetna representatives understand complex cases. New hires face months of learning these unwritten rules. When you're growing, you don't want to be losing experienced staff and onboarding new ones simultaneously.

Higher patient volumes mean more verification work, which can make burnout more likely and increase turnover. Less experienced staff handle increasingly complex cases while manual processes strain under volume they weren't designed to support. This occurs exactly when practices need it most - during periods of growth and expansion. 

Conclusion

Growing practices are discovering that manual eligibility verification that worked for 500 patients becomes unmanageable at 5,000, and even worse due to other complications like rising denial rates and the impact on billing staff. Administrative teams that once handled coverage checks efficiently find themselves overwhelmed.

There are effective strategies to grow without these issues. Nirvana clients, such as Brave Health and Headspace have successfully navigated these challenges. Rather than expanding operations teams, they implemented continuous coverage monitoring that handles the growing workload automatically. As a result, they didn’t have the same pressure of accuracy dropoff and turnover - and were able to scale efficiently.

Practices that invest in infrastructure designed for compounding complexity will have capacity to focus on patient care. The rest will stay buried in administrative work that grows faster than any team can manage.