Elite DNA Behavioral Health’s Success with Thoughtful AI

Elite DNA Behavioral Health is one of Florida’s largest mental health providers, with more than 30 clinics statewide. Its mission: break down barriers to care so communities can access affordable, quality mental health services.

Elite DNA’s growth after 2020 brought both new opportunities and challenges, especially in revenue cycle management. The existing manual processes were no longer sustainable for a rapidly scaling organization, resulting in:

• Frequent billing delays: Unverified insurance occasionally delayed claims processing and revenue collection.
• High eligibility denial rates: 20% of all denials stemmed from incomplete or delayed eligibility verification.
• Patient dissatisfaction: Check-in delays sometimes detracted from the seamless patient-first experience that Elite DNA strived to deliver.

To keep pace while maintaining high standards of care, the team needed a more efficient approach to insurance verification.

Elite DNA partnered with Thoughtful AI to integrate AI Agent EVA, fundamentally redefining its approach to eligibility verification. EVA seamlessly performs tasks typically done by highly trained revenue cycle staff, like verifying patient insurance coverage across multiple payer portals, reconciling discrepancies in subscriber or policy information, and updating copay details directly into the Electronic Health Record (EHR) system.

This shift replaced manual, error-prone workflows with a fully automated and proactive verification process, ensuring every patient’s insurance was validated well before their appointment.

Streamlined Pre-Visit Checks

Integrated with Elite DNA’s appointment scheduling system, EVA initiates eligibility checks four days before each visit. It verifies plan details, coverage status, and patient financial obligations by navigating payer portals, processing unstructured data, and adapting to diverse payer systems—updating the EHR with accurate information.

At the end of each day, EVA re-runs checks for patients initially flagged due to missing or erroneous insurance data. If insurance remains unresolved, EVA determines whether to retry later or escalate the case for manual follow-up. For last-minute or walk-in visits, it runs real-time checks to prevent delays due to unverified insurance. This level of responsiveness has been pivotal in improving the patient check-in experience.

Identifying and Resolving Coverage Issues

EVA intelligently identifies inconsistencies, such as mismatches in demographics or missing subscriber data. By using AI to cross-reference payer rules and historical data, it flags high-risk claims likely to be denied.

One of EVA’s most impactful capabilities is handling coordination of benefits-related issues, especially common with mental health payers. It determines whether a secondary case policy is required, adds the correct details to the patient record, and ensures that claims are submitted accurately for full reimbursement. When issues are too complex for automation, EVA escalates them to human team members for resolution, ensuring accuracy and timeliness.

Providing Actionable Insights

EVA not only performs tasks but gives Elite DNA’s RCM team real-time visibility into verification trends. Staff can quickly identify recurring issues, adjust workflows, and focus on resolving complex cases. By combining automation with analytics, EVA has resulted in more efficient use of resources and fewer disruptions during patient check-ins.