Your Eligibility & Benefits Check is Only 70% Accurate (And What to Do About the Other 30%)

You spend precious administrative hours verifying eligibility and benefits (E&B) for every new patient, only for a handful of those claims to come back denied anyway. It’s frustrating when you feel like you've checked all the boxes, yet revenue still slips through the cracks—it's the billing equivalent of a "check engine" light.

Here’s the sobering reality, straight from our Billing Director, Kelley Sonnenberg: Eligibility and benefit checks are only about 70% accurate across the industry. An E&B check is a good first step, but it is definitely not a guarantee in any way.

That missing 30% is where your practice loses revenue, manages a mounting Aging Report, and has difficult, sometimes relationship-damaging, conversations with patients about unexpected bills.

This guide breaks down why that 30% gap exists and provides the non-negotiable best practices and Standard Operating Procedures (SOPs) you need to build a stronger administrative foundation and protect your cash flow.

The Reasons for the Missing 30%: Why Eligibility & Benefit Checks Fail

If a claim is denied, it often stems from information that was either unavailable or constantly changing at the time of your check. Understanding these pitfalls is an important step to revenue cycle management success.

1. The Ever-Changing Nature of Benefits

An eligibility check provides a snapshot in time. The information you collect today can be outdated tomorrow.

• Accumulations Fluctuate: You might check benefits today and the patient owes a deductible, but tomorrow they met that deductible because they had another medical appointment. Deductible status is an ever-changing thing and is never going to be 100% accurate.

• Details Change: Claim processing is subject to change depending on the CPT codes, diagnosis codes, or even the provider seeing the patient.

• Inactivity: You could see a patient for a few sessions based on a card they gave you, only to find out later that their insurance was inactive.

2. The Network Caveats (Specific Plan Confusion)

This is one of the most common errors providers make: failing to confirm your network status with the specific plan name.

• Mistake #1: Confusing Different Plans: In many states, there are numerous versions of one insurance company. For example, in Michigan, Blue Cross Blue Shield of Michigan is different from Blue Care Network of Michigan (the HMO version). A patient might have a Blue Cross Blue Shield card, but the provider must be credentialed with the specific Blue Care Network to be in-network.

• Mistake #2: The Hidden Carve-Out: A "carve-out" is when a patient's medical insurance (say, Blue Cross Blue Shield) outsources their mental health benefits to a separate, specialized insurance company, like Magellan. If you aren't in network with that second company, your benefits will process as out-of-network.

Action Tip: Always confirm specific plan names and check for mental health carve-outs.

3. The Authorization Game-Stopper

If you miss this step, it often results in a "Game Over" denial. If a patient requires Prior Authorization, and you don't secure it before the session, this can lead to claim denials.

Insurance companies will not typically provide backdated or retroactive authorization. This is especially common with psychiatric testing and complex codes.

• Crucial Distinction: A referral from a Primary Care Physician (PCP referral) is not the same thing as a prior authorization.

How to Manage the 30% Risk: Non-Negotiable Best Practices

Since you can't rely on the 70% accuracy, you need a process that creates a safeguard for your practice. As Kelley notes, you’re talking to the SOP Queen—and she knows the path to clean claim reimbursement:

1. Create a Standard Operating Procedure (SOP)

The single most impactful action you can take is using a benefit template to ensure you get all the information every time. Your practice should function around the process rather than around the person.

• Build the Template Checklist: On your standardized template, you should track the effective date, termination date, deductible, copay, coinsurance, and out-of-pocket maximum.

• Track Session Limits: Include a place on the template to note if the patient has a limited number of sessions (e.g., 52 sessions a year).

• Authorization Check: You must always check for authorization and include a field for that confirmation on your template.

2. The Paperwork Power Play

The intake process is your first line of defense.

• Collect the Front AND Back of the Card: The front of the card has the plan ID, but the back of the card is equally important for billers and administrative staff. It has the direct provider phone number, which ensures you have the most direct line and aren't transferred to 20 different people to check benefits.

• The Reference Number Rule (Your Defense): If you are calling the insurance company, always get a reference number when they provide you benefits. If you use a portal, note the transaction ID. This reference number is your defense if the payer later claims they never provided those benefits or if the information changes.

3. Choose Your Verification Tool Wisely

Don't blindly trust your Electronic Health Record (EHR) E&B tool. Kelley recommends avoiding these internal tools because they can be confusing and not as accurate since they often pull information from a third party.

• Best Practice: Always utilize the payer-specific portal (like Cigna’s or Optum’s) or a dedicated platform like Availity, which are generally more accurate, real-time, and easy to read.

Pro Tip for Beginners: If you're just starting out, check the patient's benefit information in the payer portal, and then call the patient's plan to confirm and ensure you are interpreting the portal correctly. Once you feel confident, you can rely solely on the portal.

Conclusion: Turning Denials into Deposits

While the patient should ultimately be responsible for knowing and understanding their own benefits, the practice has a responsibility to act as a safeguard. By implementing a robust, process-driven SOP, you catch a lot of preventable errors on the front end.

Mastering these steps ensures that even when dealing with the unpredictable 30% of claims, your practice has the best defense possible, allowing you to return to focusing on patient care.

Ready to stop chasing down the other 30%?

Follow-Up Actions to Take:

• Review your E&B Process: Audit your current intake process to ensure you collect the front and back of the insurance card, every time.

• Create Your Template: Use a checklist (digital or paper) that you can standardize across your entire practice, ensuring the reference number and authorization status are always logged. A downloadable Eligibility & Benefit Check Template is available, along with other DIY Billing resources, with a subscription to the Hourglass Learning Hub.

• Start Simple: If you have too many payers, consider limiting your panels to just a few so you can become an expert in those specific benefits and quickly spot patterns.

• Hand Off the Burden: If you would rather outsource the entire process and move beyond the complexity of the 30% risk, Practice Solutions includes comprehensive benefit checks as part of our Done-for-You Billing services.

If you’re tired of wrestling with insurance denials and need an expert to help build these safeguards, reach out to Practice Solutions today!