How an Internal Medicine Practice Cut Eligibility Work 80% and Eliminated
Eligibility-Related Denials
An Internal Medicine practice managing 3,000–3,500 patient visits each month needed to evaluate 27+ eligibility, benefit, provider, and Medicare-specific data points for every scheduled patient.
CombineHealth automated the retrieval and interpretation of this information, turning a labor-intensive eligibility workflow into an action-ready pre-visit process for the front desk.
Eligibility Verification Transformed
90,000+ Eligibility Data Points to Interpret Every Month
Across commercial, Medicare, and Medicare Advantage patients, the practice needed to evaluate 27+ data points for every scheduled visit — from coverage and benefits to PCP assignment, referrals, patient responsibility, Medicare conditions, and service-level coverage.
Across 3,000-3,500 monthly visits, this meant retrieving and interpreting more than 90,000 data points every month.
A 10-person outsourced team managed the workflow, yet manual verification wasn't completely accurate and eligibility issues still contributed to approximately 5% of claims being denied.
CombineHealth Turned Eligibility Responses into Action-Ready Pre-Visit Decisions
Traditional eligibility tools could already return substantial coverage and benefit information. But staff still had to reconcile that information with patient and practice data and determine what it meant for the upcoming visit.
That meant answering questions such as:
- Is the scheduled physician the patient’s assigned PCP?
- Is a referral required?
- Is the planned service covered?
- Does the patient’s Medicare status affect billing?
- What should the front desk collect?
- Is an Annual Wellness Visit still available?
CombineHealth deployed Mark AI to automate both the retrieval and interpretation of this information.
Mark AI brings together information from payer responses and portals, Medicare sources, the practice management system, and historical records. It evaluates the information for the specific patient, provider, and scheduled visit, then produces an action-ready eligibility record showing what is verified and what requires attention.
Going beyond basic eligibility checks
For each scheduled patient, CombineHealth’s Eligibility & Verification platform evaluates:
Coverage & patient identity
Coverage status, demographics, effective dates, and primary and secondary insurance.
Provider, network & referrals
Assigned PCP, network status, plan requirements, and referrals.
Benefits & patient responsibility
Deductible, copay, coinsurance, out-of-pocket amounts, and existing balances.
Service-specific coverage
Coverage for relevant preventive and visit-specific services.
Medicare-specific conditions
Medicare Advantage, Home Health, Hospice, and other reimbursement-related conditions.
Revenue opportunities
AWV eligibility and utilization history, including whether an AWV appears to have been completed with another provider.
Exceptions requiring attention
Insurance ID errors, demographic mismatches, ambiguous network information, and other unresolved fields.
From a 10-Person Workflow to Largely Autonomous Eligibility Verification
CombineHealth transformed eligibility into a largely autonomous pre-visit workflow. 85% of cases are completed without human intervention, with 100% accuracy, while cases requiring review arrive with the verification largely completed and the specific exception flagged.
See How Eligibility Becomes an Action-Ready Decision
Download the full case study to see how CombineHealth retrieves, interprets, and presents the information the practice needs before each scheduled visit.
