Automated claims processing could solve one of the biggest challenges currently facing healthcare providers: maximizing reimbursements by minimizing denied claims. Denials have been steadily increasing over the last few years. An MGMA Stat survey found that nearly seven in ten providers witnessed a jump in denials during 2021, although the trend took hold even before COVID-19 hit. If providers rely on outdated systems and tools to process the growing volume of claims, it’s inevitable that denial rates will continue to climb. It’s not surprising then that a new Experian Health survey* revealed almost 3 in 4 providers stated that reducing claim denials takes precedence over other priorities.
Getting claims right the first time is no easy task. Traditionally, the claims management process has been labor and time intensive. Claims teams spend hundreds of hours gathering documentation, preparing claims for submission, engaging with medical clearinghouses, and then monitoring claims adjudication while they await the payer’s verdict. Should a claim be denied, more staff hours may be required to rework it for a second attempt at reimbursement. Even if administrative budgets and staffing numbers increased in line with demand, inefficient manual systems can no longer bear the burden of data to be managed.
With more providers heading into the danger zone of claim denials, automated claims processing tools are growing in popularity. These enable more efficient claims management, boosting productivity, easing pressure on staff, and above all, minimizing denials. Experian Health’s survey* found that 78% of providers are open to replacing current technologies if they are presented with compelling ROI projections, reflecting the urgency of the situation.
What is automated claims processing?
Automating claims involves the use of digital technology, software, machine learning and advanced analytics to optimize healthcare claims management.
This can include:
- pre-filling data into digital forms to avoid data input errors
- using intelligent document processing to pull unstructured information into a single, usable format
- comparing data from multiple sources and flagging inconsistencies
- providing real-time insights and status updates
- allowing multiple parties to work from interoperable data
Tools such as robotic process automation (RPA) can be used to replace manual activities, using data, logic and business rules to make decisions within certain parameters. This eases pressure on busy staff and improves efficiency, for example, when prioritizing claims to be reworked. Imagine how much faster a software program can synthesize hundreds of current and historical data points, compared to a human trying to do the same job.
There are opportunities to automate just about every stage of the claim lifecycle, from the patient’s first interaction with their provider to reimbursement.
For example, automation can be used to:
- Streamline patient onboarding and automate identity checks to avoid errors in patient information
- Verify insurance eligibility and run continuous coverage checks to see if the patient’s status has changed
- Maintain a complete electronic health record that follows the patient throughout their healthcare journey, so claims contain correct information
- Track payer policy changes and apply custom edits so that coding information is correct
- Scrub claims to find and fix any errors before they are submitted
- Submit claims to payers and monitor the claims adjudication process
- Optimize the denials management workflow and prioritize denied claims for resubmission
- Verify reimbursements and initiate patient billing processes.
Virtually any repetitive, process-driven, or paper-based task from claim creation to claim reimbursement is an opportunity for automation. As technology advances, so do the opportunities to streamline operations, reduce time to reimbursement, optimize decision-making, reduce costs and improve the patient experience.
Here are the 5 benefits of automated claims processing:
1) Automated claims processing streamlines operations
Automation’s number one benefit is allowing providers to move away from inefficient and error-prone manual processes. Staff no longer need to sift through disparate and complex coding lists, medical records and payer edits looking for the correct information to attach to a claim. Together with electronic records management, automation allows for standardized workflows, so the entire claims cycle is more consistent, and decisions are based on real-time accurate data. It helps to eliminate time spent searching for missing information, reformatting data to meet payer requirements, and trying to figure out which claims are worth reworking.
Multiple digital tools are available to optimize different tasks within the claims processing workflow. But for maximum efficiency, providers should look for solutions that work together within an integrated system. Using a single vendor makes it easier to manage data consistently and simplifies system-to-system interactions. A comprehensive claims management solution also creates a smoother user experience, for example, by allowing staff to check real-time insights within one dashboard, using one log-in.
Experian Health’s suite of healthcare claims management solutions connects each step in the claims workflow to speed up claims processing. For example, ClaimSource manages the entire claim cycle in a single, scalable online application that serves individual hospitals and physician practices through to large multi-facility health systems. It creates custom work queues and integrates electronic remittance data directly, to allow staff to prioritize high-impact claims and speed up reimbursement.
2) It saves staff time and resources
Outdated and clumsy processes can contribute to staff burnout, poor performance and difficulties attracting and retaining top talent, even more so as patient volumes return to pre-pandemic levels. By removing many time-wasting manual tasks, automated claims processing allows staff to use their time more productively. It’s particularly important amidst ongoing staffing shortages, which put additional strain on existing staff.
Some of the most time-consuming manual activities occur in the prior authorization workflow. Prior authorizations are also a common cause of claim denials. Because payer requirements around prior authorizations change frequently, staff must painstakingly check each payer’s website before submitting authorization requests to ensure that the necessary documentation is in place. Once submitted, they must log in to different payer portals to track progress. According to the American Medical Association, some physician practices spend more than two full days processing prior authorizations each week.
But with automated prior authorizations, staff can prevent delays and denials. Online prior authorizations automate inquiries and submissions without the need for user intervention, instead drawing on payer data that are already updated and stored in the system. It auto-fills the necessary information and flags where manual intervention is required. It can initiate more authorizations in less time, and guide staff to the highest-priority tasks using dynamic, exception-based work queues.
By reducing the error rate, automation also facilitates faster claims processing, which means payments can be processed and issued more quickly.
3) Automation generates more accurate and actionable insights
Automation doesn’t just save time; it also gives staff greater clarity and control over the claims process. Automated digital solutions facilitate more reliable data management to reduce errors, and generate real-time insights based on accurate information.
A large proportion of claims are denied because patient information doesn’t match the payer’s records. This can be easily avoided using robust electronic medical records that hold data in standardized formats and automatically populate forms with the correct information. Electronic data management also gives staff richer and more reliable insights, by pulling together all the information they need into a single, accessible interface.
Using an automated tracker such as Denial Workflow Manager makes it easy for staff to monitor claims, denials and remittances in one place. Not only does it track denials, holds, suspends, zero pays and appeals, but it also provides detailed analysis to help root out the causes of denials, so they can be avoided in the future. Staff can immediately see which claims need attention and resolve them much more quickly, as opposed to using manual processes.
Enhanced Claim Status complements Denial Workflow Manager by automatically generating work lists for staff, complete with actionable data to help them check off the tasks quickly and accurately. The software sends automated status requests based on each payer’s claims adjudication timeline, to see if claims are pending, denied, returned-to-provider or zero-pay transactions. This takes place before the Electronic Remittance Advice and Explanation of Benefits are processed, so staff can respond quickly and avoid unnecessary denials or delays.
Case study: Schneck Medical Center uses Denial Workflow Manager for real-time performance improvement
Schneck Medical Center used Denial Workflow Manager for real-time insights into their denial management performance to increase accuracy and reduce costs. Their existing solution didn’t offer the data and reports needed to make decisions to prevent future denials and reduce expenses, which led to a review of their revenue cycle technologies to identify opportunities to increase efficiency and accuracy and reduce costs.
Experian Health was chosen as the new vendor because of its ability to offer standardized solutions across the entire revenue cycle, from registration, quality assurance and checking eligibility, to claims processing and denials management, and even taking patient payments.
The Director of Patient Financial Services said:
“We have the Denials Management work queue set-up to allow all of our staff involved in reviewing denials to see those in real time. We’re able to work them more quickly because our front-end staff have immediate feedback on what happened and how they can prevent denials in future.”
4) Faster claims processing equals faster payment
According to the Council for Affordable Quality Healthcare (CAQH), the time saved by switching from manual to electronic claims processing could save the medical industry up to $1.7 billion each year. The increase in accuracy leads to more first-time pass-through rates and optimized decision-making around which claims to rework. While automation requires some upfront investment, the output tips the balance in favor of faster, higher reimbursements.
Experian Health’s Claim Scrubber solution is one example of how automated claims processing can reduce undercharges and denials, optimize staff time and improve cash flow. This program reviews each pre-billed claim, line-by-line, to check that coding details are accurate. It then applies general and payer-specific edits and verifies that the claim is free of errors before it’s submitted to the payer or clearinghouse. As a result, more claims are correct – and therefore paid – the first time, and staff can spend less time chasing old accounts receivable.
5) Automation can transform the patient experience
Getting claims right the first time starts at the beginning of the patient journey. A digital patient access experience is more convenient and satisfying for patients and helps prevent errors that can lead to denied claims later. Patient contact information can be automatically pre-filled so the patient can check for errors. If a patient adds new data when they’re scheduling or registering for care, that information can be automatically checked against the data already on file, and flagged if there are inconsistencies.
Further along, the efficiencies afforded by claim process automation mean patients don’t have to wait so long for confirmation that their medical expenses have been handled. Or, if they have an out-of-pocket amount to pay, they’ll get clarity about their financial responsibility much sooner. Patient portals are a great tool for helping patients track claims when and where it suits them, rather than having to wait to speak to a call center agent.
And by making the claims process more efficient, automation also releases staff from time-consuming repetitive administrative tasks so they’re free to support patients with more complex queries. Automation can elevate the customer experience with personalized communications and simplified transactions, from patient access to patient payments.
Transitioning to automated claims management
As the volume and complexity of claims to be processed increases, providers need to find ways to manage the workload, alleviate pressure on staff and prevent unnecessary revenue leakage. Working with a trusted vendor can ease the transition to automation and maximize potential cost savings. Experian Health provides industry-leading software solutions to improve healthcare claims and denials management so that more claims are clean the first time. In fact, Experian Health was voted as the top claims vendor for hospitals in the 2022 Black Book vendor survey, for the second year in a row.
Find out more about how Experian Health’s suite of Healthcare Claims Management products can help providers reduce denials, rebilling and drive up reimbursements with automated, clean and data-driven claims processing.
*survey fielded July 2022