01 the business
Pathology and lab collection network
25 collection sites, 2,000 patients a day
Front-desk staff check insurance by phone and portal, often on the day. Inactive coverage and missing authorisations are found at check-in, causing delays and later denials.
02 before
The problem
Front-desk staff check insurance by phone or portal, one patient at a time, often on the day. Inactive coverage or a missing referral is found at check-in, and visits are delayed or claims are denied later.
- Checks happen on the day, one at a time.
- Coverage problems cause queues at check-in.
- Eligibility errors lead to denied claims.
03 the build
What the AI does
- Step 1: Reads upcoming appointments a few days ahead from your scheduling system.
- Step 2: Runs electronic eligibility checks with each payer for every patient.
- Step 3: Reads the response for coverage status, co-pays, deductibles and any referral or authorisation needed.
- Step 4: Flags problems, such as inactive coverage or a missing authorisation, for the front desk to resolve before the visit.
- Step 5: Saves the result to the patient's account so check-in and billing use the same information.
paused: waiting for a person to approve
How it was put together
- Read appointments a few days ahead.
- Ran electronic eligibility checks with each payer.
- Read coverage, co-pays, deductibles and referral or authorisation needs.
- Flagged problems for the front desk and saved results for billing.
04 human in the loop
Where a person stays in charge
Front-desk staff contact patients about any coverage problem and decide how to proceed. The tool never cancels or reschedules a visit on its own.
- Front-desk staff contact patients about problems and decide next steps.
- The tool never cancels or reschedules a visit.
- Results are stored only in the patient's account.
05 rollout
From kickoff to live in 6 weeks
- Weeks 1–2Connect scheduling and the clearinghouse; agree problem rules.
- Weeks 3–4Run for three sites and compare with manual checks.
- Weeks 5–6Extend to all sites.
06 after
What changes
Coverage problems are solved before patients arrive, check-in is quicker, and fewer claims are denied for eligibility reasons.
Assume 2,000 patients a day, a quarter needing a manual check today at 12 minutes each.
2,000 × 25% × 12 minutes = 6,000 minutes, or 100 staff hours a day across the network.
What to measure
- Appointments checked before the day.
- Check-in delays for coverage reasons.
- Eligibility-related denials.
- Front-desk time on checks.
07 evidence
What the research says
Moving US healthcare admin transactions from manual to automated could save $20 billion a year; a prior authorisation takes providers about 24 minutes by phone, fax or email and 16 minutes through a portal.
HealthCare.gov insurers denied 20% of in-network claims in 2023, and fewer than 1% of denied claims were appealed.
KFF, Claims denials and appeals in ACA Marketplace plans in 2023 (opens in a new tab) · 2025
08 lessons
Mistakes to avoid
- Checking too late. Run checks days ahead.
- Ignoring authorisation flags.
- Not saving results for billing.
09 questions
Common questions
- How much time does automation save?
- The 2024 CAQH Index estimates electronic eligibility checks save medical providers about 12 minutes per transaction compared with manual methods.
- Does it work outside the US?
- Insurance checks are mostly a US need, but the same approach works for private insurers and funding checks elsewhere.