Coverage Discovery: How to Get It Right (Before Admission)

When a patient referral hits your inbox, time is tight — and so is your margin for error. If insurance details are missing or unclear, you're left making high-stakes decisions without the full picture. That’s where coverage discovery can help find insurance policy details that patients and caregivers may not know about. 

In this article, we’ll walk through:

• What coverage discovery actually is (and what it’s not)

• Why identifying coverage early helps you avoid denials later

• How ExaCare can make the discovery process faster, smarter, and more accurate

What is coverage discovery?

It’s easy to assume you’ve got a patient’s insurance figured out, until a claim gets denied, and you’re stuck chasing coverage after the fact. Coverage discovery helps you avoid that scramble.

At its core, coverage discovery is the process of uncovering active insurance policies that a patient hasn’t disclosed or that aren’t obvious in the referral packet. It goes beyond asking patients or families for details, as they might not know the full picture either.

What makes it different from standard verification?

Standard insurance verification checks whether the coverage a patient says they have is active and what it includes. Coverage discovery, on the other hand, asks a different question: Is there any active insurance tied to this patient, even if no one has told us about it?

It’s the difference between confirming what you know and actively looking for what you don’t. This is especially important in post-acute care settings where:

• Patients often arrive after long hospital stays with incomplete documentation.

• Families are overwhelmed and may miss or misunderstand insurance details.

• Staff relying solely on self-reported or hospital-provided info can lead to misclassified self-pay cases.

Who uses coverage discovery, and why?

Skilled nursing facilities, home health providers, and post-acute care centers use coverage discovery to avoid preventable denials and uncover billable insurance they might otherwise miss.

It’s especially useful when:

• A referral comes in with missing or vague insurance information.

• You're seeing frequent denials related to eligibility.

• You want to reduce the number of patients incorrectly labeled as self-pay.

If your team manually verifies coverage or scrambles after admissions to resolve claim issues, implementing a discovery process could be the difference between being reactive and staying in control.

Why coverage discovery matters

Coverage discovery matters because it prevents claim denials by finding missing insurance information before billing. It also improves payment timelines by supporting clean claims that process faster. 

When your team misses active coverage, it’s not just a small paperwork issue — it can stall your reimbursement, hurt your margins, and create more follow-up work than your staff has time for.

Prevents avoidable claim denials

One of the top reasons claims get denied is because no coverage was on file at the time of billing. But in many cases, the patient did have insurance — the information just wasn’t captured or verified in time. 

Coverage discovery gives your team a way to find that coverage before admission, making it easier to submit clean claims and avoid unnecessary denials.

Reduces self-pay misclassification

If a patient’s insurance isn’t properly identified, they’re often marked as self-pay. This causes confusion for families, delays for billing teams, and a much higher risk that you won’t get paid.

Coverage discovery helps ensure you’re not relying solely on what’s disclosed in a referral or intake form. It gives you a second layer of confirmation before you commit to accepting the patient.

Improves reimbursement timelines

Clean claims move faster through the system. When you catch insurance gaps upfront, your billing team can submit accurate information without delays, resubmissions, or appeals.

That means fewer AR headaches and a more reliable revenue stream — especially important in long-term care, where cash flow is always tight.

How insurance discovery tools work

Good insurance discovery tools do the heavy lifting in the background. Instead of waiting for staff to dig through documents or follow up with hospitals, these tools search payer systems directly to find active coverage tied to each patient.

Real-time vs. batch lookups

Discovery tools typically work in two ways:

• Real-time lookups are triggered at the point of intake. They’re best used when time matters, like when a referral comes in, and you need to make a fast decision.
  
  

• Batch lookups allow you to scan groups of patients all at once. These are useful when auditing existing residents, prepping for recertification, or reviewing denied claims.

Facilities that combine both approaches often see the biggest results: fewer missed payers, more accurate classifications, and fewer billing delays.

Matching against payer databases

Use basic demographic data discovery tools and cross-reference national and regional insurance databases. These might include Medicare, Medicaid, and commercial payers. When a match is found, the tool returns details like coverage type, effective dates, and plan IDs so your team can bill correctly the first time.

Surfaces verified coverage for billing teams

Once insurance is discovered, the tool delivers the information in a format your billing team can act on. The best tools don’t just generate raw search results, they organize and highlight key coverage information so it’s clear what to bill, when, and where.

This can dramatically cut down on time spent chasing payers or reviewing claims.

Identifies hidden primary and secondary coverage

Some patients have more than one active policy, but unless your team knows where to look, that secondary coverage can be missed.

Discovery tools can help you spot both primary and secondary insurance, which is critical for coordinating benefits and maximizing reimbursement. This also protects your facility from losing money to incorrect payer prioritization.

Supports re-checks after admission or during denials

Coverage discovery isn’t a one-and-done process. Some payers activate coverage after the hospital stay begins, or families apply for Medicaid once the patient is already admitted. Tools that allow for automated or manual re-checks make it easier to catch these updates and reprocess claims accurately — before they get written off.

When should you run coverage discovery?

If you’re only verifying coverage once (at the start of intake), you’re probably missing key opportunities to catch updates, prevent denials, and recover revenue. Coverage discovery isn’t just a one-time step; it’s part of a smarter intake and billing strategy.

The best time is before or during intake

Ideally, coverage discovery should run as soon as a referral comes in. That’s when you’re making the big decision: Can we take this patient? And what’s the reimbursement outlook? If you catch missing or secondary insurance before admission, you can fix it without slowing down intake — or risking a bad claim down the line.

Re-checking post-admission can save you

Even if insurance details looked solid at the time of admission, things change. Medicaid applications get approved after the fact. Payers update their systems. Or a patient’s coverage kicks in retroactively. 

Running a second discovery check 24 to 48 hours after admission can help you catch these shifts and make corrections before your claim is submitted.

Use it to follow up on denied claims

When a claim gets denied for “no coverage on file,” it’s not always a dead end. Coverage may have existed — but just wasn’t known or verified in time. Running discovery as part of your denial management process can uncover missed payers and open the door to re-billing.

Use it when coverage is incomplete or unclear

Sometimes a referral includes a payer name, but no ID number. Or a patient lists coverage, but you can’t confirm it’s active. Rather than relying on partial information, running discovery gives you verified data straight from payer systems, so you’re not making guesses that could cost you later.

Re-check after major changes in patient status

If a patient’s length of stay changes, their payer mix might change too. For example, someone initially admitted as Medicare Part A may switch to Medicaid long-term care. Discovery helps you verify that the right payer is in place as those transitions happen, especially during complex discharge planning or level-of-care changes.

What happens if insurance is found after admission?

You still have options, but the clock is ticking. If discovery finds active insurance after a patient is admitted, you may be able to backdate coverage or resubmit claims. The key is acting quickly. Many facilities miss out on reimbursement simply because they don’t catch the update in time.

To avoid that scenario altogether, build coverage discovery into your daily workflow. Don’t wait for a denial to find out something was missed.

Best practices for getting it right

Getting the most out of health insurance discovery isn’t just about using the tool — it’s about making sure your team has a reliable, repeatable process. These best practices can help make discovery a seamless part of your intake and billing routines:

• Always verify insurance before admission: It sounds obvious, but when intake teams are moving fast, this step can get skipped — especially when a referral appears to have complete insurance info. A quick discovery check can prevent costly oversights and give your billing team more confidence in the claims they’re submitting.

• Automate where you can: Manual verification slows everything down and leaves room for error. Using a tool that automatically checks referral packets for coverage as referrals come in (like ExaCare) means your team gets accurate insurance data without having to chase it down. It’s faster, more consistent, and far less stressful.

• Align admissions and billing teams: Coverage discovery doesn’t belong to just one department. When admissions and billing work together, your facility gets a clearer picture of risk and reimbursement. Set up shared workflows where discovery results are reviewed early — and used to guide both care decisions and claim prep.

• Track discovery success rates and patterns: Are you seeing fewer denials since adding discovery? Are certain referral sources sending incomplete insurance info more often than others? Tracking these trends helps you identify where gaps still exist and where your team might need more training or better tools.

• Re-run discovery before submitting long-stay claims: If a resident has been with you for several weeks or months, it’s worth re-checking their coverage before submitting a long-stay claim. Coverage types and eligibility can change — especially for Medicaid or secondary commercial plans. A quick re-check can prevent a denial that might otherwise go unnoticed until weeks later.

• Set internal checkpoints for re-checking coverage: Create simple checkpoints — like 48 hours post-admission, or during pre-bill review — where discovery is automatically re-run. This creates a safety net to catch updates before claims are finalized, without adding a huge burden to your staff’s workload.

Frequently asked questions

1. What are the top insurance discovery vendors?

There are several vendors in the insurance discovery space, each offering different features. Some of the more established names include Experian Health, Waystar, and TransUnion Healthcare.

When evaluating tools, it’s important to look at how they integrate with your existing systems, how accurate their matches are, and how easily your team can use the results to improve reimbursement.

2. Is insurance discovery HIPAA-compliant?

Yes, insurance discovery tools are built to comply with HIPAA regulations. They use secure methods to query payer databases and protect patient information throughout the process.

As with any software handling protected health information, it’s important to ensure the vendor has strong data security practices and signs a Business Associate Agreement (BAA).

3. Can coverage discovery be automated?

Yes, many coverage discovery tools offer automated processes. Instead of running manual checks, these tools can automatically scan payer databases as soon as a referral comes in or during scheduled workflows like post-admission or pre-bill reviews.

Automation helps reduce delays, lower error rates, and save your staff valuable time.

4. Can ExaCare find patient insurance?

ExaCare makes it easier to find patient or claim details quickly by pulling key information from referral packets into one view. While ExaCare is not an extensive insurance discovery tool, it gives skilled nursing and post-acute care providers faster access to the data they need to evaluate a patient’s financial fit.

By highlighting key insurance information early in the referral review process, ExaCare supports quicker, more informed admissions decisions and helps teams spot potential reimbursement risks upfront.

How ExaCare enhances coverage discovery

Coverage discovery is only as strong as the workflow it’s part of. When your intake and billing teams have to hunt for information across referrals, portals, and outdated systems, even the best discovery tools can fall short.

That’s why the real win comes from integrating coverage insight into a faster, smarter admissions process.

ExaCare helps you do exactly that. Built for skilled nursing and post-acute care providers, ExaCare uses AI to cut through the noise of bulky referral packets and surface the information that matters — including insurance details, right when you need it.

Instead of toggling between platforms or relying on incomplete documentation, your team gets a clear, organized view of clinical and financial fit from the very beginning.

With ExaCare, your team can:

• Instantly screen referrals with AI that summarizes hundreds of pages into actionable insights
  
  

• Manage all your hospital referral sources in one centralized platform
  
  

• Automate insurance verification, flag high-cost medications, and estimate reimbursement
  
  

• Track performance with built-in analytics that help you improve response times and hospital relationships
  
  

• Collaborate across admissions, clinical, and billing teams in a single, unified workspace

By reducing delays, eliminating guesswork, and improving visibility into patient coverage, ExaCare helps your facility move faster, and with greater confidence, through every admission decision.

Schedule a demo.