Halving Monthly Backlog – Eligibility Automation in Action
See how AI automation simplified eligibility checks across multiple systems.
Project Scope
In early 2025, we partnered with a fast-growing U.S. health-tech company to automate one of their key RCM processes - eligibility checks.
Verifying patient eligibility and active coverage across multiple payer portals consumed hours of manual labour every day. Their RCM team was overwhelmed, spending most of their time verifying thousands of insurance details.
As the verification queue grew, eligibility checks became a serious bottleneck.
That’s when automation became the natural next step.
(This case has been anonymized for confidentiality.)
Main Challenge | Keeping the Pace
Every RCM leader knows that bad data = higher CTC rates.
Missing or incorrect PHI – such as patient identifiers, coverage details, or demographic data, always results in one or more of the following:
- Decreased process efficiency.
- Lowered Net Promoter Score (NPS),
- Hours lost to rework and payer follow-ups,
In this particular case, the RCM team relied on a batch-style eligibility workflow, which delayed updates and inflated backlogs.
On top of that their custom built platform relied on multiple disconnected systems for patient, provider, and payer data. The fragmentation forced constant system-hopping and double entry – a direct driver of rising Cost-to-Collect (CTC).
Hiring more people was neither sustainable nor strategic.
In short:
Pathways between systems weren’t integrated, coverage details were often outdated, and copay amounts were calculated manually.
Each verification was taking around five minutes.
Multiply that by thousands of patients every week, and you’ll understand the challenge this client was facing.
This RCM team needed a scalable, accurate, and compliant way to automate the verification process:
- One that would connect payer portals, internal systems, and EHRs seamlessly;
- One that would run 24/7 without bloating CTC or blowing the budget;
- One that was crafted by our devs team - to put it simply.
Solution | Eligibility Checks Automation to the Rescue!
Our goal was clear: automate insurance verification end-to-end – with full accuracy, auditability, and HIPAA compliance.
The board outlined three priorities:
- Reduce manual workload and verification time,
- Prevent denials linked to incorrect or expired coverage,
- Lower the overall CTC without growing headcount.
After a series of process discovery workshops, we began to build.
The first step was setting up the architecture on Amazon Web Services (AWS) – a comprehensive cloud platform offering storage, databases, and computing power.
Then, we followed it with setting up an automation framework platform, which allowed us to automate processes.
In a few short weeks, we designed a tailored-to-needs Eligibility Checks Automation System.
The automation now works across multiple payer portals and middleware systems – even those without APIs – performing real-time checks on insurance coverage, copays, and deductibles.
The process runs fully unattended on virtual machines orchestrated through the automation platform, ensuring continuous eligibility verification with no human intervention.
Each transaction is logged and archived via AWS, maintaining a full audit trail in compliance with HIPAA and PHI security standards.
The solution operates fully within HIPAA requirements by restricting all processing to the minimum necessary data: payer details, provider information, patient identifiers (ID and date of birth), and the service type with its procedure code.
To top that off, we also ensured strict access controls allowing only authorized AI workflows to access and handle PHI.
How does the eligibility checker work?
When a new patient profile is added or updated, our eligibility checker automatically:
- Logs into the relevant payer portals such as Availity,
- Validates plan status, effective dates, and benefit coverage,
- Extracts copay and deductible information,
- Flags inactive or mismatched coverage,
- Writes the verified data directly back into the EHR,
- Sends alerts via Slack or email for exceptions that require review.
“The Flobotics team is knowledgeable, easy to work with, and gets things done. They built a solution that scales effortlessly and works exactly as promised.”
- CTO, U.S. Healthcare Platform
Results
The project was a major success.
With process automation, eligibility bottlenecks disappeared.
With a modest investment, our client eliminated one of the most error-prone steps in their revenue cycle and regained lots of capacity. Their RCM team could finally focus on complex, high-value cases – instead of repetitive verification work.
With all verification gates and decision loops we introduced, our client’s data was stored securely and consistently across all systems.
We’re especially proud that this specific healthcare company could finally rely on real-time, validated payer information. This minor improvement significantly increased their Net Promoter Score (NPS)
It was also designed to scale as patients' volume grows.
Too good to be true?
Wait untill you read about the ROI metrics. The results speak for themselves:
- Eligibility checks duration time dropped by 90%
- 5x faster eligibility check than manual handling
Summary
What once was a manual, time-consuming workflow is now a silent background process – just as it should be.
By replacing repetitive manual verification with an intelligent and scalable automation layer, the client unlocked significant ROI – saving time, money, and staff capacity.
This project shows how automating eligibility verification can completely transform RCM performance in the healthcare industry.
Which brings us to the following point:
At Flobotics, we skip the fluff, speak from the heart, and stay focused on real outcomes - not hype. Ready to scale without growing headcount?
Let’s talk!
Let’s talk. In just 15 minutes, we’ll cut through the noise and see if automation works for you.
