Everyone has been there. You show up at the doctor’s office, provide the front desk with your insurance information, and proceed with your appointment. At the end of your visit, you stop by the front desk and wait to find out how much you owe. Typically you’re only asked for a small co-pay, but then, months later, you receive a totally unexpected bill in the mail asking you to pay a significantly larger amount.
This unexpected bill occurs because it is nearly impossible for a medical service provider to determine on the spot, with accuracy, what percentage of a service is covered by the patient’s healthcare plan. The reason for this goes way back to the Health Insurance Portability and Accountability Act (HIPAA), established in 1996 and included administrative simplifications, which requires that all providers use the X12 Electronic Data Interchange format to process patient eligibility inquiries. Fast forward 20 years, and providers are still using decades-old technology, with its complex and outdated programming languages. This causes an enormous amount of friction across American healthcare.
While at first this predicament just sounds like an annoyance for both patient and provider, it is actually hugely harmful to the entire system. At Eligible, we provide a service that automates healthcare billing and insurance eligibility. We’ve found that the likelihood of a patient paying their bill drops by 1.2 percent every week that a provider waits to bill them for their services. Providers are frequently forced to forfeit up to 50 percent of what they’re owed by patients, in order to collect even a portion of the amount due—a problem that is only growing as the patient’s share of the cost burden continues to rise.
To address this problem while still working within the confines of the archaic X12 Electronic Data Interchange format, Eligible has created a set of data transformation and processing techniques that allow us to convert X12 representations from thousands of different insurers and policies into clear, reliable, interoperable abstractions. These can then be easily processed by healthcare providers and payers.
Our team applies machine-learning algorithms to extract patterns from millions of cases. We use natural language processing to analyze the structure of each of these thousands of policies to accurately predict how much a patient will be charged at the time of service, months before their claim is adjudicated. The end result is increased transparency and convenience for both patient and provider. That causes patient satisfaction ratings to skyrocket and healthcare providers to lock in dramatically more revenue at the time of service.
Today Eligible’s software automates eligibility for over 2,000 insurance companies which cover more than 90 percent of the insured U.S. population. Major providers like RadNet or the Cleveland Clinic now have kiosks installed throughout their facilities where patients can scan emailed bar codes in order to see exactly how much their service will cost, even before proceeding with the appointment. Eligible integrations also help power services like Zocdoc, Oscar, and HealthTap, enabling eligibility and cost-transparency at every step of the healthcare process. Provider revenues climb and doctors are free to focus on what they do best – provide patients with the best possible care.
Katelyn Gleason is CEO and founder of Eligible.