Why Eligibility Verification & Prior Authorization Are Non-Negotiable in 2025
Healthcare billing is getting more complex, and so is insurance scrutiny. One of the most common causes of claim denials? Lack of proper eligibility verification and prior authorization.
Healthcare billing is getting more complex, and so is insurance scrutiny. One of the mostcommon causes of claim denials? Lack of propereligibility verificationandprior authorization.
If youre not checking patient benefits before rendering services or failing to obtain payer approvals in time, youre riskingunpaid claims and revenue loss. Heres how you can fix that and get paid faster.
What Is Eligibility Verification?
Eligibility Verificationis the process of confirming a patients insurance coverage, active policy status, co-pays, deductibles, and benefits before services are provided.
Why it matters:
If you treat a patient without checking coverage, you risk deliveringnon-reimbursable services.
What Is Prior Authorization?
Prior Authorization (PA)means obtaining formal approval from the insurance providerbeforespecific treatments, medications, or procedures.
Why its critical:
Many payersdeny claimsif prior approval is not documented even if the service was medically necessary.
Top 5 Reasons You Must Prioritize These Processes
-
?Reduces Claim Denials by 60%+
-
?Improves Patient Experience(No surprise bills!)
-
?Ensures Timely Reimbursement
-
?Avoids Compliance Risks
-
?Optimizes Front-End RCM Efficiency
Real-World Impact: Why Most Denials Are Preventable
According to CMS and MGMA reports,over 80% of claim denials are preventable and eligibility & authorization issues are at the top of that list.
Without these checks:
-
Providers deliver non-covered services unknowingly
-
Claims get rejected or delayed
-
Patient dissatisfaction rises
