Mastering End-of-Year Benefit Resets with Nirvana

To ensure effective billing and a transparent patient experience, administrative teams should endeavor to routinely re-verify benefits, especially after benefit resets when coverage changes can occur. 

To learn more about benefit resets and their negative impacts, check out How Annual Benefit Resets Complicate Billing and Disrupt Access to Care.

Current manual benefit verification solutions cannot keep up with the number of benefit resets most practices experience during common open enrollment periods, such as from November 1st to January 15th. This inadequacy has detrimental consequences such as canceled appointments, revenue cycle disruptions, claim denials, write-offs, and low patient sentiment. 

New-age solutions that can accurately and efficiently verify benefits are required to alleviate strain on administrative teams, provide clarity to patients, and empower practitioners to focus on care. 

To this end, Nirvana’s Continuous Coverage leverages machine learning (ML) and artificial intelligence (AI) to simplify benefit verification and help billing teams master benefit resets.

Current Benefit Verification Solutions for Benefit Resets

Current benefit verification is highly fragmented, relying upon expert billers using a combination of insurer-provided eligibility portals, EHR solutions, and manual calling. Unfortunately, eligibility portals, the most efficient of these methods, struggle to handle the ever-growing complexity of the health insurance space. Carve-outs, changing co-pays, and telehealth benefits have all proven challenging, not to mention the delays caused by the slow deployment of policy updates. 

In some cases, payers only refresh their systems to reflect plan changes and benefit resets for the new year as late as March. This leaves billing teams scrambling to verify benefits over the phone as patients schedule or attend appointments. Nirvana has found these calls can take upwards of 45 minutes per patient. During busy periods, such as after benefit resets, a high volume of calls can result in manual benefit verification taking up to seven days for larger providers. 

Consequently, benefits go unverified, placing providers and patients at financial risk. 

The Difference Maker: Nirvana’s Continuous Coverage

Alternatively, Nirvana’s AI-powered benefit verification and continuous coverage monitoring help billing teams anticipate benefit resets and handle them appropriately. 

Deployed either through the  platform or an EHR integration, Nirvana’s API automatically monitors for payer updates during the reset period. For example, as of publication, 73.5% of all Optum plans have already updated their 2025 benefits. Nirvana will continue monitoring for year-end policy changes until March 2025. 

Once an update is detected, Nirvana sends an alert to billers, verification specialists, and intake coordinators, allowing providers to confidently schedule appointments for the upcoming year as soon as November. Teams that use Nirvana can reduce the number of manual benefit resets required during the open enrollment period by 50%. 

Thanks to this increase in efficiency, Nirvana frees administrative teams to focus on more complex insurance cases, improving billing accuracy. When Nirvana’s API detects a potential denial risk, it is prioritized in biller workflows, ensuring even the most difficult verification cases can be handled promptly. 

All of this comes together in a single, biller tool, consolidating knowledge and saving administrative time. 

Continuous Coverage In Action

Between 2023 and 2024, a large, behavioral health organization with more than 100,000 patients experienced significant growth. While great for the business, this placed a strain upon the billing team with a 46% increase in policies requiring manual verification. Heading into the busy, benefit reset season, it also found itself short-staffed and sought a benefit verification solution that could scale with the organization. 

Upon implementing Nirvana’s benefit verification and continuous coverage monitoring via direct integration with its existing EHR, this partner saw an increase in biller efficiency by 110%. Additionally, 21,000 claims were flagged as at risk of denial, preventing downstream revenue loss. 

According to its RCM leader: “Nirvana helps us get information upfront and empowers our providers to have conversations with our clients proactively…. We have already seen decreased denials and increased turnaround times in identifying insurance changes. Nirvana helps us fulfill our mission, which is to make getting help easy.”

Empowering Patients and Providers Year-Round with Nirvana 

Maintaining financial transparency between patients and providers is paramount to consistent, successful care and practice profitability. During the benefit reset period, patients are especially at risk of receiving unexpected bills as deductibles reset or coverage changes. By partnering with Nirvana, providers can ensure patients receive upfront cost estimations even during hectic, reset periods. 

According to NRC Health, 75% of consumers would choose a provider who shares prices over one who doesn’t, and 66% of consumers believe price transparency is very important regarding where they go for routine healthcare visits. Cost transparency is essential for strong patient sentiment and retention. It is estimated that increasing patient retention by just 5% can increase provider profits anywhere from 25% to 95%.  

The benefit reset period is a challenging time for providers nationwide, especially as antiquated systems have failed to scale with the volume and complexity of insurance plans. Nirvana’s API is a significant step forward for providers and patients, helping the busy end-of-year reset period pass with ease.