The healthcare industry is plagued by confusion surrounding the terms “insurance eligibility,” “discovery,” and “verification.” These terms are often used interchangeably, but they refer to distinct processes within revenue cycle management (RCM).

Eligibility determines if a patient’s insurance covers a specific healthcare service. Discovery identifies coverage a patient might not be aware of or has not disclosed. Verification confirms the activity of a known insurance policy.

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As healthcare costs continue to rise, employers are increasingly focusing on strategies to manage these expenses. According to a survey by the Business Group on Health, addressing healthcare costs is the top priority for employers, with a particular emphasis on reducing spending on overall healthcare, affordability for employees and the company, and pharmacy costs.

Several factors contribute to rising healthcare costs, including the increasing prevalence of chronic diseases and mental health conditions, as well as the high cost of certain medications like GLP-1s. To mitigate these costs, employers are implementing various strategies such as prior authorizations, weight management programs, and pharmaceutical cost-control measures.

While employers are taking steps to address these challenges, the ongoing rise in healthcare costs presents a significant challenge for many organizations.

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