Loading...

Healthcare runs on revenue

Published: July 25, 2018 by Experian Health

As most doctors will say, healthcare is about helping patients, not making money. However, these two goals aren’t as separate as some would assume. In order to help their patients, healthcare providers need to buy equipment, pay salaries, and spend money to maintain an effective, efficient customer experience. Revenue is what makes healthcare work, so preserving revenue should be a main priority for healthcare administrators.

That’s how Stacy Calvaruso, assistant vice president of patient services and revenue cycle at Louisiana Children’s Medical Center (LCMC) Health, approaches her job. “Revenue preservation is a term that we use in our organization to talk about how we’re going to ensure that we’re maintaining all the money that we can possibly collect for the services that we provide for our community,” Calvaruso says. “Everyone is being asked to do more with less, and patient access or the revenue cycle is no different than the clinical areas. We have to ensure that we’re able to collect all the money and all the income that we generate as an organization so that we can put more money back into the community to provide more services to more patients.”

For help with revenue preservation, Calvaruso’s team uses Experian Health’s revenue cycle management tools. The full suite of Experian Health’s revenue management products help LCMC Health facilitate patient access, manage contracts, process and submit claims, and streamline collections. Here’s a closer look at how Experian Health approaches each stage of the revenue preservation process.

Patient Access

With 86 percent of leading medical practices seeing an increase in payer prior authorization, having accurate and comprehensive patient data is crucial to getting patients the treatment they need with fewer denials from insurers.

Experian Health can help by verifying patient information at the point of service. From there, automated software coordinates patient data across all connected facilities so customers, doctors, and insurers are better informed about possible treatment options and how much they’re likely to cost, eliminating any surprises in the payment or collections process.

According to Calvaruso, a transparent process helps to prevent repeated work, which is a major cause of revenue loss. “Instead of calling a patient after the fact about a denial or incorrect insurance information, we’re able to call them on the front end to let them know that we’ve verified their benefits, we know what the estimate of their out-of-pocket payment is going to be, we’ve talked to their doctor, and we’re ready for them to come and have these services,” she says.

Experian Health’s Patient Access tools make it quick and easy to find the right information and avoid miscommunications and delays that affect revenue preservation. Hospital staff will be grateful for the lightened workflow and improved outcomes for both customers and administrators.

Contract Management

One of the most common clogs in revenue collection comes from unclear contract management. Without the right data to analyze contract compliance, hospitals will struggle to get accurate payments from insurers and customers.

Calvaruso says that one of the cornerstones of her revenue preservation philosophy is reducing the avoidable denials; Experian Health’s contract management tools can analyze and audit contracts to ensure payer compliance and clarify anything that could lead to such a denial. Experian Health’s contract management tools also provide patients with more accurate estimates of treatment costsOne recent survey of 54 hospitals found that getting a price estimate is a frustrating process for patients; another poll found that 46 percent of younger patients aren’t paying their full bill at the point of service because they didn’t have an accurate cost estimate.

Having accurate contract management data can make a big difference at both the point of service and in later payment collections. Experian Health’s contract management tools can not only increase the revenue a hospital collects, but they can also improve the financial experience and build better relationships with customers and insurers.

Claims

Everybody makes mistakes, but given the amount of stress that healthcare providers are under, it’s more likely that they’ll make mistakes on routine paperwork like claims forms, which can lead to the kind of rework that hospitals loathe and that eats away at revenue.

On top of that, without a streamlined system in place, it’s often unclear where the initial problem occurred, which means administrators can’t correct the problem for next time. “We make sure we’ve done all the work in the beginning to prevent the rework,” Calvaruso says. “One way we can do that is by using that lean process that assists us with identifying where we can improve.”

Experian Health’s solutions helped Calvaruso develop that type of process. ClaimSource helps organizations prioritize the claims that need immediate attention, which saves time and reduces the number of tardy claim submissions. To avoid errors in the claims themselves, Experian Health’s Claims Scrubber® makes sure clean claims are submitted the first time, eliminating the dreaded rework.

Collections

Submitting new claims after denials is aggravating, but bad debt write-offs are even more harmful to revenue preservation — it’s money that the organization will never see, no matter how much more work is put in.

The only way to ensure accurate collections is to minimize the risk of denial in the first place. As Calvaruso says, a key component of preserving revenue is moving back-office work to the front end. For collections, this means accurately verifying patient identity and analyzing litigation risks.

Of course, not every situation can be accounted for, and there will always be issues with collections, Experian Health’s collections solutions make it easier for organizations to prioritize their past-due accounts and pursue them effectively.

No healthcare organization will ever receive 100 percent of the revenue it’s due, but taking the right steps to preserve revenue can mitigate much of the loss and keep things running smoothly. With healthy revenue management, healthcare providers can better help the people who need them most.

Related Posts

Learn the fundamentals of claims management in healthcare, including key steps, common challenges, and best practices to improve reimbursement rates and reduce denials.

Published: August 7, 2025 by Experian Health

Learn how key provisions in the 2025 budget bill may impact Medicaid, uncompensated care, and hospital finances - and how to prepare with the right revenue cycle tools.

Published: August 4, 2025 by Experian Health

Manual prior authorization workflows represent one of the most tedious and expensive aspects of the healthcare revenue cycle. However, despite access to automated prior authorization software, only 31% of providers use electronic prior authorizations, according to the Council for Affordable Quality Healthcare (CAQH). The CAQH predicts that providers who switch to automated prior authorization software could not only gain back valuable staff time, but also see significant cost savings. What is prior authorization and why is it important? In healthcare, prior authorizations are when providers and payers decide in advance if a patient's insurance plan will pay for a specific treatment. Prior authorizations are crucial to reimbursements and keeping revenue cycles on track. Providers that offer services without prior authorization are unlikely to receive reimbursement from the patient's insurer. This can result in unpaid medical bills, leaving billing teams chasing patient collections or writing off bad debt. During the prior authorization process, providers submit a rationale for a proposed treatment to the payer. The request is approved or denied based on certain criteria, including payer policies and medical necessity. The payer may reject a prior authorization request if the treatment or service isn't covered under the patient's insurance plan, if it's not considered medically necessary or if a more affordable alternative is available. Simple paperwork errors, like missed deadlines or incomplete documentation when submitting a prior authorization, may also result in a denial. Challenges of manual prior authorization processes Despite the importance of prior authorizations in the revenue cycle, tedious manual prior authorization processes present challenges for many healthcare providers. Some of the key obstacles providers face using manual prior authorization include: Heavy administrative burden Healthcare providers spend a significant amount of time starting, completing and revising prior authorization paperwork. An AMA survey found that 86% of physicians say prior authorization has increased healthcare resource usage. At the same time, additional AMA data reports that providers spend around 13 hours working on 39 prior authorizations each week, and nearly one-third of providers report that these prior authorization requests usually end up being denied. Changing payer policies Keeping up with multiple payers and ever-evolving payer policies adds strain on staff and ultimately results in prior authorization denials. Changes are often unannounced, making it hard for providers to stay on top of updates. As a result, prior authorization submissions aren’t always accurate and may be based on outdated rules. This can lead to instant rejection and wasted time correcting and resubmitting requests. Inefficient workflows Prior authorization requirements can be complicated, especially when providers are juggling different payers, standards and service lines. Coping with these complexities often puts strain on manual systems, especially when multiple staff and notetaking methods are involved. Staff members may each get different pieces of information from payer websites (or over the phone) and not have the ability to benefit from their shared knowledge efficiently. Navigating communication hurdles and rapid payer information changes can result in workflow inefficiencies that snowball quickly. How prior authorization software can improve efficiency Replacing manual prior authorizations processes with automated prior authorization software can help providers improve efficiency. Here are some key ways providers benefit from automated prior authorization solutions, like Experian Health's Authorizations. Reduces manual interventions: This solution limits guesswork, human errors, and misinterpretations by automating data originating from the EMRs. Automation saves staff time and energy and prevents frustration. Stays current with latest payer policies: The prior authorization system stays up-to-date with the latest regulations and payer requirements. Automatic updates provide staff with the most current information, eliminating the need for staff to visit multiple payer websites or cross-check data by hand. Provides real-time updates: Providers can promptly clear authorizations for service by proactively identifying authorization status as pending, denied or authorized. This allows physicians to make timely treatment plans and for patients to avoid disruptions in care. Reduces risk of denials: Through automation, electronic prior authorization software ensures the accuracy and completeness of submissions by automatically checking with payers and vendors to validate that the authorization is on file. Payers and providers also get a shared view of account information, reducing the need for prolonged discussions about the status of authorization and rework requests. Key features to look for in prior authorization software When implementing prior authorization software, look for a solution that offers a wide range of features to automate and streamline the prior authorization process. Experian Health's prior authorization solution, Authorizations, for instance, offers healthcare providers the following key features: Real-time knowledgebase: Access to up-to-date prior authorization requirements and criteria in the National Payer Rulesets Submissions support: Removes guesswork and directs users to the correct payer portal based on procedure Automated inquiries: Automates the prior authorization payer inquiry process Enhanced workflow: Dynamic work queues display status and guides users through next steps Postback: Allows users to easily send authorization status, number and validity dates to health information systems (HIS) and practice management systems (PMS) Image storage: Receives and securely stores payer responses in an integrated document imaging system Reconciliation: Provides insights into authorization variations and helps resolve them, so staff can take proactive steps to prevent denials and appeals Integration with electronic health records and billing systems: Why it matters Providers often choose a prior authorizations platform that seamlessly integrates with existing Electronic Health Records (EHR) and billing systems for maximum efficiency. Solutions like Experian Health's automated prior authorization management tool, Authorizations, easily adapt to existing processes. This eliminates the need for a complete workflow overhaul and minimizes the learning curve for staff. Embracing prior authorization software for a more efficient revenue cycle Revenue cycle leaders who implement prior authorization automation strategies could see significant savings – $494 million annually as an industry, according to CAQH data.  Claims and revenue management processes are often complex and outdated, costing healthcare organizations time and money. High denial rates and slow reimbursements can hurt cash flow and get in the way of financial stability. Automating prior authorization can reduce claim denials, speed up reimbursements and improve the bottom line. Learn more about how Experian Health's electronic prior authorization software, Authorizations, uses automation to achieve greater consistency and efficiency for healthcare organizations. Learn more Contact us

Published: July 30, 2025 by Experian Health

Subscribe to our blog

Enter your name and email for the latest updates.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Subscribe to the Experian Health blog

Get the latest industry news and updates!
Subscribe