Automated Insurance Eligibility Verification Workflow for an Orthopedic Practice

Overview

Built an automated eligibility verification workflow for an orthopedic practice where staff were manually checking insurance coverage for every scheduled procedure, often the day before or even the morning of. The system automatically checks eligibility as soon as a procedure is scheduled and flags any coverage issues early enough for staff to resolve them before the patient arrives. This was especially important for orthopedic procedures, where a coverage surprise on the day of surgery creates real disruption for both the patient and the surgical schedule. The workflow integrates with the client's existing clearinghouse rather than requiring a new insurance-verification vendor. Staff at an orthopedic practice were manually checking insurance coverage for scheduled procedures, often the day before or morning of, so coverage surprises regularly disrupted the surgical schedule. We built an automated eligibility verification workflow that checks coverage as soon as a procedure is scheduled and flags issues early enough for staff to resolve them well before the patient arrives, integrated with the client's existing clearinghouse. We mapped the practice's exact procedure-scheduling workflow and clearinghouse relationship first, then built the automated check to trigger at the same point scheduling already happened, requiring no new step for staff. It was tested against a batch of upcoming procedures in parallel with the manual process before fully replacing it. Coverage issues are now caught an average of several days earlier than the practice's prior day-of process, meaningfully reducing last-minute schedule disruptions for both staff and patients.