Case Study: Provider verifies Medicare insurance eligibility

Client Profile

Network of mission-driven not-for-profit regional hospices with a shared vision to strengthen and preserve community-based care and services that has over 1,300 employees.

Scope Highlights

  • Medicare coverage eligibility determination, ongoing status, and billing requirements
  • Alerts identifying non-Medicare insurance scenarios
  • NetSmart Electronic Medical Record (EMR) and existing patient data warehouse
  • myAbility clearinghouse
  • Blue Prism Cloud (BPC)


The provider cares for and serves hospice patients who may be eligible for Medicare insurance in addition to other private coverage. However, their Medicare eligibility determination process required ongoing manual review for changing circumstances and updates to the patient’s EMR documentation. The billing team wanted to automate the Medicare insurance verification for hospice patients.


Automation uses NetSmart electronic medical record (EMR) and the organization’s data warehouse in order to identify patients being served. Next, it uses myAbility to evaluate patient’s current and prior circumstances to determine eligibility for Medicare insurance. The results are added to the patient’s EMR for use by claims and billing teams. Also, non-Medicare insurance outcomes are flagged for review by the Billing team.


Over 2,000 hours saved annually

100% data entry error reduction

Reduced cycle time