Eligibility teams should be backed by strong auditing, performance review and continuous learning.

You are only as good as your employees. Equip your enrollment team for success by structuring processes aided by technology and reporting.

Successful management in the eligibility realm stems from two overarching themes that are fundamental to operational excellence:

  1. Medicaid, Social Security Disability, and other federal and state eligibility programs are complex requiring expertise and the utmost attention to detail.
  2. Eligibility enrollment is a human-intensive activity. Advocating for patients and understanding the requirements for eligibility, as well as tracking the accounts through application and acceptance, require a lot of human interaction.

Internal Auditing

The eligibility process starts with screening and requires real people inputting information into a system, which means accounting for the margin of human error. But with continuous internal auditing in place, you can ensure the accuracy of information being entered, and in turn, help the likelihood of applications being approved.

When repeat errors occur, mentor your eligibility specialists on how to learn from common claim mistakes and emphasize the importance of being precise.


Productivity benchmarks should be measured differently for each subset of the revenue cycle. When collecting bad debt, for instance, goals can be set for how many dollars to collect within a certain number of days.

However, it requires more overhead to determine if eligibility is even an option for a patient, so you can’t simply measure productivity in terms of how many applications your enrollment specialists submit. What you should be tracking is how many patients can be seen per day:

  • Is that number steady?
  • Are interactions falling off?
  • If so, why?

If patient volume is steady but the number patients seen is dropping off, then operational leadership should evaluate any barriers to success and get to the root of the problem.

Continuous Learning

A big challenge for eligibility leaders is ensuring staff is abreast of changes to federal, state and industry regulations. This is one benefit that having an eligibility vendor with strong relationships with public agencies can deliver to your organization.

Also, schedule huddles every week where you can spotlight a team member and allow the opportunity to present best practices from difficult eligibility cases for the benefit of the department.

To learn more about how to strengthen your eligibility and enrollment program or to identify opportunities to reduce large self-pay balances, contact our eligibility and advocacy experts.