Gregory examines how Annual Reverification (AR) processes must evolve in response to changing payer dynamics and increasing benefit complexity. Rather than focusing solely on throughput and operational efficiency, he argues for the importance of more nuanced strategies that help ensure patients maintain access to therapy—even when coverage details shift behind the scenes.
To learn about CareMetx’s solution, download the case study: Rethinking Annual Reverification: A Strategic, Multi-Layered Approach to Protecting Patient Access.
Read on for Gregory’s insights.
Beyond Throughput: Building Reverification Strategies That Safeguard Access
By Gregory Morris, Chief Strategy Officer, CareMetx
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Reverification season forces a critical question every year: is your patient access strategy built to confirm coverage or to protect it?
For many brands, Annual Reverification (AR) has traditionally been about throughput—verifying benefits at scale, as quickly as possible. While that operational lift is essential, speed alone can’t account for today’s complexity. Coverage types are shifting, authorization rules are changing, and a simple “policy active” response is no longer enough to confirm that a patient can access their therapy.
Without a strategy designed to catch what standard checks miss—like benefit type changes, new prior authorization triggers, or a shift from Medicare Fee-for-Service to Medicare Advantage—patients are left exposed. Providers may bill the wrong payer. Claims may be denied. And all of it can happen behind the scenes of what looked like a successful reverification. Speedy results do matter, but only when they’re paired with the kind of thoroughness that actually protects access.
Access Depends on the Details
Whether a patient is covered under Medicare, a commercial plan, or supported by foundation funding, the common thread is increasing complexity. Plan designs are changing, and transitions between benefit types are becoming more frequent, often without patients realizing how their medication coverage has been impacted.
A one-size-fits-all reverification model may confirm coverage, but it might miss the plan shift that triggers prior authorization or overlook the lapse in foundation enrollment that now requires rescreening. As access becomes more fragile in this way, reverification must evolve to anticipate, not just react to, these kinds of challenges.
What Happens When Reverification Misses the Bigger Picture
Take Evelyn, a (fictional) 74-year-old living outside Orlando. She receives injections to treat wet age-related macular degeneration, typically covered under Medicare Part B through a buy-and-bill model.
During open enrollment, Evelyn opted into a Medicare Advantage (MA) plan, attracted by $0 premiums and added benefits like dental and vision coverage. It seemed like a smarter, more cost-effective choice. What she didn’t realize was how that decision would change the rules for accessing her medication.
Her provider still had her traditional Medicare card on file, and during a routine eligibility check, she showed as “active” with Medicare. But that status masked a critical shift: the billing pathway, provider network, and prior authorization requirements had all changed.
Unaware, her ophthalmologist billed Medicare Fee-for-Service as usual. A few days before her next injection, the claim was denied. Prior authorization was now required, and there wasn’t enough time to secure one.
The office called to reschedule, and suggested Evelyn follow up with her insurance provider. But she was confused; she hadn’t realized the plan change would affect her treatment. With impaired vision and little comfort navigating insurance questions, she waited, assuming her provider would sort it out. Her injection was missed.
For Evelyn, that delay meant a return of vision symptoms and added anxiety about her care. For the brand, it was an avoidable lapse in therapy, not due to loss of coverage, but because a reverification process failed to catch what had changed.
The Risk of Oversimplifying Eligibility
While the growth of Medicare Advantage has made these issues more visible, similar risks exist across all payer types. Patients with commercial coverage may face new prior authorization requirements after a plan shift or formulary update. Those supported by foundations may lose eligibility if financial documentation isn’t renewed in time. And IRA-related benefit design changes are reshaping cost structures in ways that can impact therapy decisions if not caught early.
Traditional AR programs often focus on confirming eligibility in bulk. But in a system where plan types, coverage terms, and patient affordability can shift overnight, that approach can fall short of what’s needed to maintain continuity of care.
A Strategic, Layered Approach to AR
At CareMetx, we take a different view of Annual Reverification, one built for both scale and specificity. Our approach is designed to not only confirm coverage but identify what has changed and what that means for the patient, provider, and brand. Key components include:
- Proactively identifying plan changes, not just confirming active status
- Deploying Medicare Action Plans that alert specialty pharmacies and providers when a patient’s insurance pathway has shifted
- Screening for foundation renewal risks and alternative funding eligibility as part of the reverification process
- Stratifying patients based on upcoming appointments to deliver updates in a timely, relevant manner
- Routing benefit summaries directly into provider workflows
This layered model helps prevent disruption, reduce provider burden, and maintain trust with patients navigating uncertain coverage.
Build a Reverification Strategy That Fits
Annual Reverification is no longer just a back-office process. It’s a strategic opportunity to support patients through change, maintain provider confidence, and ensure patient care doesn’t suffer due to unseen access barriers.
Whether you're navigating high volumes, Medicare transitions, or foundation renewals, we can help you plan with a model built for precision, flexibility, and impact. Download Rethinking Annual Reverification: A Strategic, Multi-Layered Approach to Protecting Patient Access to see how one brand reimagined its AR strategy to protect patient access.
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