Eligibility Verification and Prior Authorization: The 75% Denial Reduction Strategy

85% of preventable claim denialsoriginate from errors ineligibility verification and prior authorization(American Medical Association, 2025). These frontline processes protect revenue and prevent costly rework.

The Cost of Inefficiency

• Eligibility failures: Cause 27% of denials ($23/claim rework cost)

• Authorization gaps: Lead to 45% denial rates for high-risk services

• Payment delays: Average 22 days for unauthorized claims
  (MGMA 2024 RCM Benchmark Report)

3 Data-Driven Optimization Tactics

1. Real-Time Eligibility Verification

• Automate coverage checks24h pre-service via payer APIs

• Critical focus areas:

  • Active/inactive coverage (23% of denials)

  • Benefit limitations ($18k/month/clinic underpayments)

  • Referral requirements

2. Prior Authorization Precision

• High-risk services requiring auth:

  • 92% of advanced imaging

  • 87% of specialty drugs

  • 78% of surgical procedures

• Best practices:

  • Submit requests within 24h of scheduling

  • Attach clinical documentation (?63% rejections)

  • Use specialty-specific tracking tools

3. Technology Integration

• AI predicts auth needs with 94% accuracy during scheduling

• Reduces staff workload by 35%

• Cuts retro-authorizations by 80%

Documented Results

Implementation Roadmap

1. Integrate real-time verificationwith payer APIs

2. Standardize authorization workflows

3. Monitor weekly KPIs:

   • Auth turnaround time (<48h)

   • Eligibility error rate (<2%)

"Clinics masteringeligibility verification and prior authorizationreduce denials by 82%."
HFMA 2025