EPISODE SUMMARY

In this essential episode (with Jeremy flying solo as Kathryn welcomes their third child!), we tackle the critical third territory on the RCM Game Board: Eligibility and Benefits Verification. Think of E&B as your practice's scouting phase. We break down exactly what E&B means, why it’s a non-negotiable step before any claim is mentioned , and how mastering this repeatable five-step workflow is the key to preventing those costly, frustrating surprises for both you and your patients. We’ll dive deep into:

The two crucial parts of E&B: checking eligibility (is the policy active with me?) and benefits (what does the patient owe?).

The nightmare of Prior Authorization (PA) and why correctly checking for this requirement is the punchline to avoiding guaranteed denials.

The non-negotiable conversation with your patient about their financial responsibility—the game-changer that builds trust and prevents billing surprises.

A real-world case study of a group practice that lost over $20,000 in two months because they missed this crucial step (and how they recovered).

This is all part of a sound practice management strategy, ultimately letting you claim victory for your bottom line. It's time to stop the claim denials and turn them into deposits.

KEYWORDS

Revenue Cycle Management, RCM, Insurance Billing, Private Practice, Practice Management, Eligibility and Benefits, Prior Authorization,  Claim Denials, Patient Care, Cash Flow

TAKEAWAYS

E&B is the Cornerstone: Eligibility and Benefits verification is the third step and a cornerstone of the entire front-end RCM process. It must happen before there is even mention of a claim.

The Two Checks: Eligibility is scouting to confirm the policy is active and you are In-Network. 

Benefits is determining the cost-sharing responsibilities (deductible, copay, coinsurance, out-of-pocket maximum).

PA is the Payment Key: A required Prior Authorization that is not handled correctly guarantees a denied claim. Getting that pre-approval is like getting a special key that unlocks payment.

Non-Negotiable Communication: You must clearly explain the patient's financial responsibility before the appointment. This transparency shifts the dynamic from "Why am I getting this bill?" to "Thank you for letting me know what to expect".

Repeat the Process: Benefits change all the time! This is not a one-and-done process. Continuously update benefits and benefit verification for accuracy and patient satisfaction.

CHAPTERS

00:00 Introduction to Revenue Cycle Management

01:59 Understanding Eligibility and Benefits Verification

05:15 The Workflow of Eligibility and Benefits

09:58 Prior Authorization: A Critical Step

11:24 Communicating with Patients Effectively

13:45 Tools for Managing Eligibility and Benefits

16:02 Case Study: The Importance of Verification

18:28 Conclusion: Turning Process into Practice

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.

Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.

Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.

Images: Eligibility & Benefits, Insurance Contact Reference List, E&B Template, Benefit Summary Email Template, KPI Dashboard

Get full access to The Claim Game at jeremyzug.substack.com/subscribe