Introducing Lana
Lana is the practice’s eligibility line. Before a visit, she calls the payer, asks whether the patient is covered for medical nutrition therapy, what the copay is, how many visits are left, and whether a referral or a prior authorization is needed. Then she writes the answer on the patient’s record, with the reference number and the recording beside it.
We built her because the call is the part of the job nobody wants and nobody can skip. A portal tells you a member is active. It does not tell you that the plan caps nutrition visits at six a year, that three were used in March, or that the representative’s name was Denise. The provider line does. So Lana uses the provider line.
Real phone calls
Lana dials the payer’s provider services number, the same one a biller dials. She gets through the IVR, speaks in the register the machine expects, and waits on hold like everyone else. When a live representative picks up, she identifies herself, gives the practice’s NPI and tax ID, and asks her questions in the order a seasoned biller would. She does not scrape a portal, and she does not guess from a plan name.
The read-back protocol
Every identifier is read back before a question is asked. Member ID, date of birth, the NPI, the date of service: each is spoken digit by digit and confirmed by the representative. If the confirmation does not come, Lana repeats it. This costs a few seconds and it is the reason the answer is about the right person. A verification that quietly ran on the wrong member ID is worse than no verification at all.
Reference numbers
At the end of a call, Lana asks for the call reference and reads it back too. The reference number is filed on the visit with the date, the representative’s name where one was given, and the questions that were answered. When a claim is later denied for a benefit the payer confirmed, the reference number is the first thing the appeal cites.
Recordings under the BAA
Every call is recorded and transcribed. The audio is kept with the transcript under the practice’s business associate agreement, and the benefit facts are pulled into fields the practice can read at a glance: active, copay, visits remaining, referral needed, authorization needed. The recording is the receipt. If a denial contradicts what the payer said on the phone, the practice can answer with the payer’s own words.
Flags, not guesses
Representatives are sometimes unsure. Systems are sometimes down. A plan sometimes has a benefit the representative cannot find. When any of that happens, Lana does not produce an answer. She flags the visit for review, says why, and moves on. The count of invented answers in the pilot is 0, and it is the number we care about most. A wrong answer with confidence costs the practice a claim; a flag costs a person two minutes.
Batches
A practice does not verify one patient at a time. Tomorrow’s schedule is verified tonight, and a new program’s fifty patients arrive as a CSV. Lana counts the rows in the browser, verifies each one when the payer line is open, and returns a row per patient with the recording behind it. Calls placed after a payer closes wait for the line to open. Only the calls that need a human come to a human, with the reason.
What the numbers say so far
The average verification call in the pilot runs 41 seconds from pickup to reference number. The longest live representative call recorded is 12.6 minutes. Both are on the record with their recordings, and both will move as more payers and more plans go through the line.
What Lana is not
She is not a billing service and she does not decide anything. She verifies, she files, and she flags. The dietitian still reads the flags at 8:00 and decides what to do about the visit at 9:15. The practice still owns its relationship with the payer. Lana makes the call so the practice does not have to, and keeps the evidence so the practice can prove what it was told.
Where she runs
Lana is part of auro, on the same record as the chart, the ledger and the shelf. A verification is a line on the visit, a claim is a line on the ledger, and the two meet when the remittance arrives. There is nothing to export and nothing to retype.
If your practice runs eligibility by phone today, we would like to show you a call. Book a demo and bring a schedule.
