Well, it’s blitz season. For some, this phrase evokes the thought of football or a famous reindeer. But within the lab industry from coast to coast, conference to conference, you constantly hear that labs are on an all-out blitz to find opportunities to cut costs, save on staff and increase collections. One area healthcare organizations and specifically laboratory organizations can harness to drive collections’ improvements and cut staff is with insurance verification.

I receive frequent emails from labs on this subject, so let’s look at common questions I receive on the subject of insurance verification to better understand the tangible benefits of TELCOR’s benefits eligibility solution:

Q: We see claim denials for invalid insurance on the backend. How would TELCOR’s solution fit into our workflow and reduce these denials?

A: TELCOR RCM automatically verifies insurance before a claim goes out the door. Patient account records with eligibility failures are flagged, preventing claims from going out to payers erroneously. This translates to a reduction in claim errors, receiving payment sooner and improved days sales outstanding (DSO) metrics.

Q: Many of our patients are repeat patients and some have government plans where eligibility changes monthly. Can TELCOR help us verify insurance on a frequent basis without adding staff?

A: Definitely! TELCOR RCM has the flexibility to perform benefits eligibility checking based on different triggers. For example, eligibility can be checked each time a new payer is added to a patient’s account record. Our system can also check eligibility each time a new test is sent from the LIS to billing for a patient. Parameters can also be applied to define a minimum number of days between eligibility checks. In essence, you can configure the system to check if a patient has active coverage for Medicaid every 30 days when new transactions are received.

Q: Hey Kwami – Hope all is well! Our lab has a high population of patients that present with Medicare, but their claims need to be sent to a specific MCO. Is there a solution for this scenario?

A: Yes, we have a solution. If a patient presents with Medicare, TELCOR RCM will verify their Medicare coverage. In the process, if we find an MCO or a replacement plan in the returned data from the payer, rules are defined to allow that MCO payer or replacement plan to be saved to the patient’s account in TELCOR RCM. From this point, TELCOR RCM automatically verifies the patient’s coverage with the MCO or replacement plan. If coverage is confirmed, claims will be directed to the correct payer for adjudication. All of this happens without user intervention.

Q: Our confidence in the data coming from our front-end systems is lacking. Can TELCOR’s benefits eligibility functionality improve our situation?

A: I hear you. This is an issue where many labs struggle. Capturing quality information upfront without slowing down the testing process in the lab is a constant battle. TELCOR RCM automatically generates an eligibility request based on various triggers. As the payer returns demographic information on the subscriber and/or dependent, TELCOR RCM automatically saves updates for Last name, First Name, Member ID#, Address, City, State, Zip and Country. This ensures demographic information in the billing system matches what the payer has on file for expediency in claims processing. Additionally, our process minimizes billing staff phone calls to clients and patients to obtain correct information.

Most labs perform some level of eligibility checking but they often lack the tools to adequately address many of the questions listed above. Eligibility may not be a silver bullet to combating downward reimbursement trends, but it can certainly provide a boost to your cash collections and increase productivity within your billing team. If you have similar questions on this topic and want to know how TELCOR RCM can help, please contact us.

Kwami Edwards


Kwami Edwards, vice president, RCM implementations, has more than 15 years of health care experience with a strong background in workflow redesign and change management.  In his current role, Kwami works with owners and executives to help ensure successful implementations and continued reengineering support.