Claims & Contract Management

For patient access leaders at large healthcare organizations, the pressure is mounting and has been building for some time. Healthcare claim denials are climbing. Staffing is stretched, and the tools healthcare organizations have relied on for years are no longer enough. But what if providers could stop denials before they start? Welcome to the new era of denial prevention in healthcare, powered by predictive intelligence. Experian Health's innovative artificial intelligence (AI) solutions, Patient Access Curator and AI Advantage™, were designed to help organizations prevent denials before they occur. Join us for an exclusive session exploring how Experian Health is reshaping the way health systems manage Coordination of Benefits (COB). Discover how AI is transforming revenue cycle management by eliminating manual errors, reducing denials, and unlocking millions in recoverable revenue. Register now > The denial spiral explained: A systemic challenge in revenue cycle management  Claim denials aren't just a back-end billing issue. They're a symptom of upstream breakdowns—often rooted in inaccurate or incomplete patient data at registration. According to Experian Health's 2024 State of Claims Survey, 46% of denials are caused by missing or incorrect information. And the cost of reworking a denied claim? $25 for providers and $181 for hospitals. The result? A denial spiral that drains resources, delays reimbursements, and frustrates patients and staff alike.  Why Epic users are especially vulnerable While Epic is a powerful EHR platform, many Epic-based organizations still rely on staff to make complex decisions at registration. Questions like: Is this coverage primary? Should discovery be run? Is this data accurate? ...are often left to frontline staff. This guesswork leads to inconsistent outcomes—and denials. What's needed is a layer of predictive intelligence that works within Epic to automate and correct data before it becomes a problem.  How Patient Access Curator fixes registration errors Patient Access Curator is that layer. Patient Access Curator is an all-in-one solution that automatically finds and corrects patient data across eligibility, Coordination of Benefits (COB) primacy, Medicare Beneficiary Identifiers (MBI), demographics and insurance discovery—within seconds. It integrates directly into Epic workflows, eliminating the need for staff to toggle between systems or make judgment calls on the fly. Instead of relying on registrars to catch every error, Patient Access Curator uses machine learning and predictive analytics to: - Identify and correct bad data in real time - Return comprehensive coverage directly into Epic - Reduce denials, write-offs, and vendor fees - Improve staff morale by removing administrative burden As one early-adopting Patient Access Curator client puts it: "If your current workflow still depends on frontline decisions, you're not just risking denials—you're building them in."  Predictive intelligence in healthcare: AI Advantage at work While Patient Access Curator fixes the front end, AI Advantage tackles the middle of the revenue cycle, where claims are scrubbed, edited, and submitted. At Schneck Medical Center, AI Advantage helped reduce denials by 4.6% per month and cut denial resolution time by 4x. The tool flags high-risk claims before submission and routes them to the right biller for correction. It also triages denials based on the likelihood of reimbursement, so staff can focus on the claims that matter most. Together, Patient Access Curator and AI Advantage form a closed-loop system: - Patient Access Curator ensures clean data at registration - AI Advantage predicts and prevents denials mid-cycle - Both tools integrate seamlessly with Epic and ClaimSource®  Why predictive denial prevention matters for patient access leaders  By implementing denial management technology and predictive intelligence, healthcare teams aren't just managing workflows; they're managing risk. Every inaccurate field, every missed coverage, every manual decision is a potential denial. Patient Access Curator and AI Advantage remove that risk by replacing guesswork with certainty. And the benefits go beyond revenue: - Fewer denials mean fewer patient callbacks and less frustration - Cleaner data means faster reimbursements and fewer write-offs - Automation means staff can focus on patients, not paperwork As Jason Considine, President at Experian Health, recently shared: "Our mission is to simplify healthcare. That starts by getting it right the first time, before a claim is ever submitted. With the power of AI and predictive intelligence, we're no longer waiting for denials to happen; we're helping providers proactively prevent them. Tools like Patient Access Curator and AI Advantage allow healthcare organizations to identify issues at the point of registration and throughout the revenue cycle, so teams can focus on care, not corrections. It's about working smarter, reducing risk and protecting revenue."  Denial prevention checklist: Preparing patient access teams for predictive denial prevention  Denial prevention is here, but what if billing teams aren't quite ready? To move toward a predictive denial prevention strategy, healthcare organizations can invest in the following five areas:   Audit front-end workflowsMap out every step from patient registration to claim submission. Identify where manual decisions are being made—especially around eligibility, COB, and insurance discovery. Ask: "Where are we relying on staff judgment instead of system intelligence?" Train staff on data quality awarenessReinforce the impact of inaccurate or incomplete data on downstream denials. Use real examples to show how a single missed field can lead to rework, write-offs, or patient frustration. Introduce the concept of "first-touch accuracy" as a team-wide goal. Evaluate Epic integration readinessAssess whether current Epic environments are configured to support automation tools like Patient Access Curator. Work with IT to assess whether the current setup allows for real-time data correction and coverage updates. Confirm that teams understand how new tools will integrate into their existing workflows, not replace them. Establish a denial prevention task forceBring together leaders from patient access, billing, IT and revenue cycle to align on goals. Assign ownership for key metrics like clean claim rate, denial rate, and registration accuracy. Use this group to pilot new tools like Patient Access Curator and AI Advantage and gather feedback from frontline users. Communicate the "Why" behind the changeFrame automation as a way to reduce burnout, not replace jobs. Highlight how tools like Patient Access Curator eliminate guesswork and free up staff to focus on patient care. Share success stories from peers (like Schneck Medical Center) to build confidence and momentum. The bottom line: Strategic denial prevention is the future Denial management is reactive. Denial prevention is strategic. For healthcare organizations using Epic, Patient Access Curator and AI Advantage offer a smarter, faster and more scalable way to increase reimbursements and improve the patient experience. Learn more about how Experian Health can help protect revenue, reduce staff burdens and reduce claim denials—starting at the first touchpoint. Learn more Contact us

KEY TAKEAWAYS: Survey data shows that healthcare providers find it harder to secure reimbursement for their services. Automation, staff training and analytics are the keys to preventing denials, improving accuracy and streamlining every step of the claims process. Experian Health's integrated claims management solutions are designed to close the claims gap and accelerate reimbursement. Claims management has become one of the most pressing challenges in healthcare billing. In Experian Health's 2024 State of Claims survey, 77% of providers said they were moderately to extremely concerned that payers won't reimburse them, largely due to changing payer policies and prior authorization requirements. Billing teams are left to work through dense code lists and figure out each payer's distinct playbook, often without the tools or time to catch mistakes. Managing claims efficiently is essential to ensure accurate and timely reimbursement. What is claims management in healthcare? Claims management is the process of preparing, submitting and following up on healthcare claims to ensure providers are paid for the care they deliver. It spans the entire revenue cycle, from verifying coverage during patient intake through final settlement. For revenue cycle teams, good claims management is what keeps finances on track. But with the volume of patients, claims and complex payer rules continuing to increase, the pressure is on organizations to tighten up their processes. Three key findings from the State of Claims survey show what they are up against, when compared with metrics from 2022: 73% of providers say claim denials are increasing 67% report longer reimbursement timelines 55% have seen a rise in claim errors Each denied or delayed claim adds to the administrative burden. However, when claims are submitted correctly the first time, staff can focus on patients instead of paperwork. The claims management process step by step Clean claims start with getting the basics right. "Once you let bad data in the door, it's like a virus," says Jordan Levitt, Senior Vice President at Experian Health. "Every action you take once bad data enters your system is wasting resources." Each of the following steps is a chance to keep the claim moving: Patient intake and verification Staff collect and verify patient demographic information, insurance details and eligibility at patient intake. If any of the information is missing or incorrect, the risk of denial increases immediately. Experian Health's flagship Patient Access Curator addresses this problem directly, using artificial intelligence (AI) and robotic process automation to automatically check and verify these details.   Case study: Experian Health and Exact Sciences See how Exact Sciences used Patient Access Curator to reduce denials by 50% and add $100 million to their bottom line in six months. Medical coding Coding is where clinical services become billable. Staff must select the correct codes from thousands of options covering diagnosis, procedure and supply. If the codes don't match the care provided or a modifier is left out, the claim will come back, leaving money on the table. Claim submission At this stage, all the key data is packaged together and sent to the payer, often through a clearinghouse. Claims should be reviewed line by line for errors before filing, but relying on manual processes is slow and highly risky. Automation offers a better chance at catching issues before the claim reaches the payer. Adjudication and payment posting Once the payer reviews the claim, they'll validate the services, apply negotiated rates and determine payment or denial. Payment posting closes the loop, allowing providers to reconcile accounts quickly and flag underpayments or errors needing further action. Denial management and appeals Not every claim gets paid the first time. When denials come in, teams need to know what went wrong to fix the issue and get the claim resubmitted quickly. Denial management software identifies the reasons for denials and organizes work queues for faster resolution. Patient billing and collections Anything insurance doesn't cover is billed to the patient. If the bill is confusing or shows up late, it's less likely to be paid. Upfront conversations, flexible payment options and convenient point-of-service collections can improve collection rates and patient satisfaction. Best practices for effective claims management Getting ahead of the claims challenge isn't just about fixing denials after the fact, but about preventing them in the first place. Automation, staff training and visibility into what's working (or not) all play a role. Implementing automation and technology Manual work and disconnected systems are a drag on reimbursement. Automation helps standardize routine tasks, reduce errors tied to human input and create consistent workflows that can handle sudden surges in patient volumes. AI takes this to the next level, by predicting denials, flagging coding errors or coverage issues before submission and prioritizing claims that need attention. For example: ClaimSource® is an automated claims management system that organizes claims activity from a single hub. This system makes claims editing and submissions more efficient, by performing customizable edits and checking for errors before submission. On the back end, AI Advantage™ uses AI and machine learning to predict claim outcomes and push urgent tasks to the front of the queue, so staff can spend time on the claims that matter most financially.   Case Study: Experian Health and Schneck Medical Center See how Schneck Medical Center used AI Advantage to achieve a 4.6% average monthly decrease in denials. Training and education for staff Successful claims management depends on a confident team. Staff should undergo regular training to stay current on payer rules, policy changes, coding updates and get support to understand new technology. To that end, Experian Health offers live training and on-demand webinars for teams to hear about the latest industry best practices and to see how others are using different tools. Hands-on consultancy support is also available to help teams get up and running with claims management products. Monitoring and analyzing claims data To improve claims performance, staff also need to be able to see where claims might be getting stuck. Tracking key performance indicators like clean claim rate, denial rate and days in accounts receivable helps staff spot issues. Integrated revenue cycle management tools bring everything together in one place so management can see the full picture and make sense of their data.   Blog: How to choose the right key performance indicators for your revenue cycle Find opportunities to prevent revenue leakage by building a healthcare revenue cycle KPI dashboard populated with the right medical billing metrics. Common challenges in claims management and how to overcome them Even with best practices in place, there will always be challenges and uncertainty. Claims pass through multiple departments, which means multiple opportunities for miscommunications or mistakes. Aligning workflows and claims management systems can reduce friction and help keep data secure. Another hurdle is managing the growing number of tools in use. The 2024 State of Claims report shows that one in five providers uses at least three revenue cycle solutions to pull together each claim, creating more complexity than clarity. Again, choosing claims management software from a single supplier will ensure a neat and efficient process. Finally, there's the challenge of meeting changing patient expectations. For 65% of patients, managing healthcare is overwhelming, especially when it comes to understanding costs and coverage. Organizations must maintain fast, accurate and transparent claims processing for better patient experiences. Next steps for strengthening your claims management approach The impact of claims management goes beyond the balance sheet, directly affecting patient satisfaction and operational efficiency. To move forward, healthcare leaders should ask: Are denial trends being tracked and addressed? Do teams have the tools and training they need? Is automation being used where it can make the most significant difference? Answering "yes" to these questions is the first step toward efficient claims management. With the right support, organizations can shift from daily firefighting to more predictable reimbursement strategies. Find out more about how Experian Health's award-winning claims management solutions help healthcare providers improve reimbursement rates and reduce denials. Learn more Contact Us

Managing claims efficiently—and reducing denials—remains one of the biggest challenges for healthcare providers. Statistics reveal that 46% of denials are caused by missing or inaccurate data, as highlighted by Experian Health's 2024 State of Claims Survey. For providers, these denials translate into endless follow-ups with patients, staff burnout, rising bad debt (which has increased by 7% year-over-year), and slim revenue margins. Reworking a denied claim costs providers an average of $25 and hospitals $181—an expense that is difficult to justify. Introducing Patient Access Curator: Automated claims accuracy from day 1 Fortunately, there is now a way to ensure claims are processed accurately from the start, without excessive effort: Patient Access Curator (PAC), Experian Health's groundbreaking new tool that uses artificial intelligence (AI) to revolutionize the claims process. As a central component of Experian Health's Patient Access portfolio, this innovative solution automates front-end processes, identifies incorrect data upfront, and resolves inaccuracies in real time, preventing costly claim denials before they occur. Introduced in early 2024, the curation tool is getting the attention of revenue cycle leaders at health systems and laboratories, with good reason.  This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds.  Join us for an exclusive session on August 21, 2025 to explore how Experian Health is reshaping the way healthcare organizations manage Coordination of Benefits (COB). Learn how automation and AI are eliminating manual errors, reducing denials and unlocking millions in recoverable revenue. Register now Built-in AI for more accurate data and seamless claims denial prevention Most issues that lead to denials crop up early in the revenue cycle, when information is missed or captured incorrectly during patient registration. For this reason, it makes sense to focus on denial prevention strategies  on the front end. With so much data to capture, manual strategies are bound to stumble. Unfortunately, many digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility and check for any billable coverage that might have been missed. Patient Access Curator takes on these tasks seamlessly, and right within Epic workflows. From patient demographics and eligibility checks to coordination of benefits (COB) primacy, Medicare Beneficiary Identifiers (MBI), and insurance discovery, the system automates these essential processes, providing precise data within moments. This solution ensures data integrity from the moment of registration by replacing manual guesswork with advanced AI-driven technology. This reduces the frequency of denials, minimizes A/R write-offs, and curtails vendor fees. Beyond enhancing efficiency, the tool safeguards the financial health of healthcare providers.  Jason Considine, President of Experian Health, says, "Our mission is to simplify healthcare. Patient Access Curator's advanced AI technology equips providers to address claim denials more effectively and efficiently than ever before."  Say goodbye to manual work with instant eligibility and insurance verification Patient Access Curator simplifies operations for billing teams, healthcare staff and patients. By removing administrative hurdles, staff can focus on patient engagement, rather than spending time on paperwork, phone calls and browsing websites for data. The outcome is improved satisfaction for both healthcare providers and their patients.  "We know this technology is revolutionizing the healthcare industry," shares Jordan Levitt, Senior Vice President at Experian Health. Levitt, who developed the AI-powered data capture technology, explains, "By delivering faster, more accurate results, providers can improve financial solvency while giving staff and patients a better experience."  Gone are the days of asking patients for insurance cards or verifying numbers and dates that might be inaccurate. With this solution, registrars and billing teams can be confident in the data they collect, right from the start.  PAC was created to replace the manual guesswork that often bogs down eligibility and insurance verification processes. From patient demographics and eligibility checks to COB primacy, MBI, and insurance discovery, this solution automates these critical touchpoints, delivering accurate data in seconds.  Fewer denials, faster reimbursements  The impact on denial prevention is unparalleled. Patient Access Curator ensures fewer claim rejections and faster payer reimbursements by identifying and correcting bad data across eligibility, COB, and discovery at the start of the revenue cycle. Providers are left with more retained revenue, which can be reinvested into what truly matters: patient care.  Patient Access Curator: Key features that set it apart Patient Access Curator differentiates itself as a comprehensive, all-in-one product that simplifies the most complex aspects of claims management. Key features include:  Real-time data correction: Fixes inaccurate data instantly without staff intervention.  Comprehensive coverage: Finds and corrects bad data across eligibility, COB primacy, MBI, demographics, and insurance discovery.  Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps Coordination of Benefits: Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing  Medicare Beneficiary Identifiers: PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support Insurance discovery: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches Demographics: The platform can quickly check and correct patient contact information.  Seamless integration: Automatically updates host systems (Epic) with verified and corrected coverage data in seconds.  The results? Fewer clicks, faster workflows, and more accurate billing processes. PAC doesn't just prevent claim denials; it transforms how healthcare teams approach patient access and revenue cycle management.  Proven ROI: How Patient Access Curator delivers $100 million boost to Exact Sciences Explore how Patient Access Curator powered a $100M improvement at Exact Sciences by automating insurance discovery and reducing claim denials. Improve financial health by focusing on patient health By eliminating redundant administrative questions, Patient Access Curator allows patients to focus on their health rather than the complexities of billing and coverage. Meanwhile, healthcare staff enjoy a boost in morale, thanks to fewer manual tasks and more efficient workflows—a benefit that can lead to higher staff retention over time.  Patient Access Curator is more than a tool; it's a game-changer for healthcare organizations looking to protect their revenue while delivering a better, more seamless experience for both staff and patients. Say goodbye to manual guesswork and hello to a smarter, faster, and more reliable way to manage claims. With PAC, healthcare organizations can finally get claims right from the start, without the hassle.  Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us

Highlights: Payer contract management software helps reduce revenue lost through denied claims and underpayments – two of the biggest pain points for providers – by validating reimbursements, supporting compliance and flagging policy changes in real time. Named "Best in KLAS" three years in a row, Experian Health's contract management tools optimize payer contracts and improve financial performance without adding staff. Experian Health's Contract Manager enabled OrthoTennessee to achieve an 86% success rate on appeals, saving time and recovering thousands of dollars. Claim denials and underpayments continue to cut into provider revenue, making them top pain points for healthcare chief financial officers. In Experian Health's 2024 State of Claims survey, 73% of providers reported an uptick in denials over the previous year, while 77% were seeing more frequent payer policy changes. When contract terms aren't up to date or properly understood, these changes can lead to costly surprises. Many healthcare organizations are turning to claims management automation to improve front-end operations and prevent downstream denials. But could they be overlooking another digital tool? Implementing payer contract management software is a practical way to strengthen early revenue cycle performance and ward off discrepancies that lead to denials. This software helps hospitals and health systems recover hundreds of thousands of dollars annually by auditing payer contracts and identifying underpayments. The role of payer software in enhancing contract efficiency Payer contracts set the terms for how providers get paid. These agreements cover details like claim submission timelines, reimbursement schedules, covered services, reimbursement rates, dispute procedures, contract duration and renegotiation terms. When managed well, they ensure providers are reimbursed accurately and promptly. However, monitoring complex payer contracts is becoming increasingly challenging for providers. According to the State of Claims survey, 43% of providers are very or extremely concerned about receiving full reimbursement. Frequent changes to pre-authorization rules and other payer policies are the main reason for this. Many contracts renew automatically or are amended with little notice, making oversight difficult. "Depending on how the contract is written, providers may receive very little notice of these changes," says Tricia Ibrahim, Director of Product Management, Contract Manager Suite. "Without a way to systematically and efficiently monitor these agreements throughout the contract term, there is simply no way for a provider to ensure they're paid properly." Payer contract management software addresses this by streamlining contract workflows and standardizing how agreements are handled. Built-in modelling tools allow providers to simulate different claim scenarios so they can negotiate terms from a stronger, well-informed position. Dashboards offer real-time insights that help staff ensure compliance, prevent denials and secure proper reimbursement. Key benefits of healthcare payer software for managing contracts A big part of the challenge for providers is that they are often juggling multiple contracts with multiple payers, including private insurers, Medicare, Medicaid and third-party administrators. Each has its own rules, rates and timelines. Without an automated way to track everything, it's easy for revenue to slip away. Payer contract management software helps by: Centralizing all contracts in one place Tracking critical dates like renewals and amendments Flagging changes in reimbursement terms Linking payer terms directly to claims workflows Identifying underpayments by comparing actual and expected reimbursements. This amounts to more than just good record-keeping: these tools offer instant feedback to reduce errors that could trigger denials. Teams save significant time because they no longer need to review contracts or chase down missing payments manually. Frances Thomas, Manager of Payer Strategy at OrthoTennessee, uses Experian Health's payer contract management software to negotiate more favorable settlements and terms with payers. "The system gives us the information we need to be successful," she says. "They can't really argue with you on that." Watch the webinar: See how OrthoTennessee achieved an 86% successful appeals rate with Contract Manager. Optimizing payer contracts with advanced contract management tools A first step in reducing denials and boosting revenue should be ensuring the revenue cycle team thoroughly understands their payer contracts. Contract management systems support this by rooting out ambiguous language, complex reimbursement terms or overly strict coding requirements. By analyzing contracts in detail, these tools identify hidden pitfalls that might go unnoticed until revenue is at risk. Experian Health's Contract Manager and Contract Analysis solution optimizes this process by checking claims before submission, then validating expected reimbursement against allowed amounts. Rates and authorization rules are populated automatically to reduce manual input, while contract mapping and real-time alerts help teams stay compliant. Providers also benefit from extra support through Experian Health's team of contract analysts, who are on hand to review contract terms, fee schedules and payment policies to ensure nothing is overlooked. This end-to-end visibility and guidance is why Experian Health's payer software has been named "Best in KLAS" for three consecutive years. One major benefit for OrthoTennessee was being able to handle claims in bulk. Thomas says, "We had over 600 claims for one day in the wrong network. I was able to take that bulk of claims and handle those. Otherwise, I was going to have to sit there and go claim by claim. It's a huge time saver to work smarter, not harder." Listen in to hear how another Experian Health client, Boston Children's Hospital, used Contract Manager to resolve underpayments and work with payers to resolve issues and errors, resulting in increased revenue. Learn more about how payer contract management software optimizes revenue, ensures compliance and streamlines payer contracts. Learn more Contact us

Healthcare providers have heard it before – high employee turnover and the constant need to train on new solutions can severely impact the efficiency of revenue cycle management (RCM) teams. As denials increase, the resources required to address them grow, putting additional strain on healthcare providers and their teams.  For decades, manual claim management has been the cornerstone of revenue cycle operations. However, with shifting payer algorithms, higher patient volumes, and evolving insurance coverages, this approach is no longer sustainable. Getting the highest percentage of claims paid with the exact amount of human capital is unachievable. Many health systems can't keep up, and RCM teams are experiencing burnout. There is a glaring need for the rapid adaptation of automation to improve front-end data collection, where reducing errors can have the highest impact on claims, and the teams responsible for them. According to Experian Health's latest State of Patient Access survey, 56% of providers say patient information errors are a primary cause of denied claims, 48% report inaccuracies in data collected at registration, and 83% emphasize the urgent need for faster, more comprehensive insurance verification.  Front-end operations are a major source of friction. Four out of the five top patient access challenges reported by providers relate to front-end data collection, including improving insurance eligibility searches, reducing errors and speeding up authorizations. Is it any wonder that these actions are typically performed by hard-working and taxed humans?   These inefficiencies don't just slow down internal workflows. Manual, error-prone processes lead to delays, claim denials and patient frustration, not to mention low morale with revenue cycle teams trying to find the errant data. Providers note that staffing shortages are compounding the problem, which suggests that tackling front-end workflows would be a strategic operational win.  How Patient Access Curator enhances revenue cycle efficiency  What if providers could take that manually laden process, integrate automation, and allow their staff to apply their revenue cycle experience, equity and strategic thinking in the right place?   Patient Access Curator (PAC) uses automation and artificial intelligence (AI) to streamline patient access and billing, address claim denials and improve data quality without the need for human intervention. This integrated solution performs rapid eligibility, coordination of benefits (COB), Medicare Beneficiary Identifier (MBI), demographics and insurance discovery checks to ensure that all data is correct on the front end, freeing teams up to focus on more strategic tasks.   It doesn't require the long training requirement of standalone products; it fits seamlessly into existing EHR systems, and works directly within the system, with no need for drawn-out onboarding programs.   According to one of the early adopters of the Patient Access Curator, their revenue cycle team is already seeing – and feeling – the results of automation.   A Senior Director of Revenue Cycle at a large Midwestern health system says, “One of the primary reasons we chose the Patient Access Curator was because it makes the normally manual work of revenue cycle much easier, which in turn improves productivity, empowerment and morale. Registrars are now able to make determinations right within the system. It's easy to use.” With so much data to capture, manual strategies are bound to stumble and apply downward pressure on those tasked with high-volume work. Patient Access Curator removes the need for manual checks on multiple payer websites and data repositories to verify insurance eligibility, and checks for any billable coverage that might have been missed. Experian Health's industry-leading claims management products are designed to simplify these processes. The  newest denial prevention technology  strengthens this suite with capabilities previously unavailable.  Efficient claims management with artificial intelligence and automation  Patient Access Curator captures and processes patient insurance data at registration using an “if-then” logic that returns multiple data points from a single inquiry, in seconds. Registration staff can leverage this technology to collect and verify much of the information they need to compile an accurate claim, with just a single click. In a matter of seconds, they'll have a comprehensive readout of:  Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps Coordination of Benefits: Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing Medicare Beneficiary Identifiers: PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support  Insurance discovery: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches Demographics: The platform can quickly check and verify patient contact information Patient Access Curator achieves such speedy results “because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer,” says Jordan Levitt, Senior Vice President of Experian Health. “This means data can be transferred easily between interfaces.” Hear how Columbus Regional Hospital has used the Patient Access Curator to simplify and streamline its revenue cycle operations. With Patient Access Curator, better data adds up to increased revenue cycle efficiency, along with the following:   Reduced errors: Automation minimizes human intervention in repetitive tasks.  Faster processing: Automated systems can handle large volumes of claims and payments much faster than manual processes, accelerating the reimbursement cycle, improving cash flow and reducing delays in revenue collection.  Enhanced compliance: Automation tools like Patient Access Curator are continually learning from inputs, and adapt to stay up-to-date with evolving regulatory requirements and payer policies. This ensures that claims are compliant, reducing the risk of denials and costly rework.  Improved denial prevention: Patient Access Curator identifies patterns in historical claim data, flagging or fixing potential errors before submission. This proactive approach helps in preventing denials and optimizing revenue recovery.  Streamlined workflows: Automation frees up staff from mundane tasks, allowing them to focus on strategic initiatives such as patient engagement and financial planning. This leads to more efficient use of resources and improved overall productivity.   At a time when revenue cycles are under increasing pressure from changing payer rules, labor dynamics and operational constraints, this new solution offers a long-awaited boost to both reimbursement rates and productivity. Patient Access Curator is available now – learn how it can help healthcare organizations boost revenue cycle efficiency and prevent claim denials in seconds. Learn more Contact us

Highlights: Healthcare claims processing is becoming more complex, putting financial stability at risk. Many organizations are turning to technology, particularly automation and artificial intelligence (AI), to improve the speed and accuracy of claims processing in healthcare Organizations that modernize their claims systems and track key performance indicators are better positioned to reduce denials and accelerate reimbursement. Healthcare claims processing is getting harder, according to Experian Health's 2024 State of Claims report. For 65% of healthcare leaders, claims management is more complex than before the pandemic. Slower reimbursements, rising denial rates and mounting administrative pressure are putting financial performance at risk. To improve speed and accuracy, many organizations are investing in technology: 45% of providers plan to invest in claims management technology in the next six months. As margins tighten, those that modernize their healthcare claims processing systems will be better equipped to stay financially strong. Understanding the current healthcare claims processing landscape Despite its central role in healthcare finance, claims processing continues to be one of the most resource-intensive and error-prone parts of the revenue cycle. Findings from the State of Claims report highlight three linked challenges that make it tough for providers to get paid promptly: rising denial rates, recurring errors that lead to even more denials, and the growing burden of rework. Denial rates are rising Claim denials are a persistent and growing issue. According to the report, 38% of healthcare leaders said that more than 10% of their claims are denied, and 11% reported denial rates over 15%. These numbers represent not just lost revenue, but significant time spent on rework and appeals. Common causes of denials The underlying reasons for denials are largely preventable. In the survey, 46% of respondents pointed to missing or inaccurate data and authorization problems as key contributors. These issues often stem from manual errors, inconsistent data entry, or gaps in communication between systems and teams. Incorrect insurance details, incomplete patient records and missing prior authorizations all lead to avoidable rejections. The cost of rework is growing As denial rates climb, so does the effort required to fix them. Almost half (48%) of respondents said they review denials manually, with three-quarters of denials handled by someone other than the person who processed the original claim. This puts extra strain on overextended revenue cycle teams on top of delayed payments. Leveraging technology for improved claims management Clearly, there's a need to reduce the manual burden. Comprehensive claims management platforms can help by automating workflows, tracking payer policies and improving claim accuracy at every stage. With claims processing tools designed to streamline decision points and flag potential issues early, revenue cycle teams can work more efficiently and sidestep disappointing financial results. For example, Denial Workflow Manager makes it easier to identify and prioritize denied claims by automating follow-up steps and assigning tasks to the right team members. Enhanced Claim Status submits automated status requests to payers, so staff can respond to pended, returned-to-provider, denied or zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed. Along with ClaimSource®, organizations can centralize claim activity and apply customizable edits and consistent formatting to reduce errors before submission. Case study: How St. Luke's Health System cut denials by 76% with Enhanced Claim Status Enhancing data accuracy for cleaner claims While many denial management strategies focus on the submission process, achieving clean claims starts much earlier in the revenue cycle. Much of the inaccurate and incomplete patient data that causes so many denials originates at registration. Patient Access Curator addresses this issue by validating critical patient and insurance information at the front end. It pulls data from multiple sources to verify insurance eligibility, confirm coverage details and flag inconsistencies in real time. By resolving errors early on, it prevents incorrect data from flowing downstream into the claim process, resulting in millions of dollars saved. As Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences notes, “You know when the Patient Access Curator went live because you can see it in our stock price. It helped us drive a $100 million bottom-line improvement within two quarters.” On the back end, a tool like Claim Scrubber bolsters clean claim strategies by reviewing pre-billed claims line by line, to catch any remaining errors. Together, this front-to-back accuracy boosts first-pass payment rates and reduces the risk of costly rework. Watch the webinar: Hear how Exact Sciences and Trinity Health used Patient Access Curator to tackle denials and make major savings. Implementing automation and AI to streamline claims processing Once claims are accurate and ready for submission, automation and artificial intelligence (AI) can help organizations work smarter and faster. Nearly half (47%) of providers already using AI consider it a competitive advantage, and it's easy to see why. Predictive tools allow teams to identify which claims are at risk of denial before they are sent, so they can intervene early and avoid costly delays. Tools like AI Advantage™ use AI and machine learning to analyze patterns in claims history and payer behavior. This solution flags claims that are likely to be denied and prioritizes them for review, helping staff focus their time where it has the greatest financial impact. By identifying potential issues in advance, organizations can reduce preventable denials and improve reimbursement rates. Analyzing key performance indicators to stay ahead Even with the right tools and processes in place, consistent results require teams to keep a close eye on performance. Regularly reviewing key performance indicators gives them the insight they need to adjust strategies and stay ahead of claim issues. Metrics like denial rates, clean claim rates and days in accounts receivable show where claims are most frequently getting stuck, where errors are recurring, and where improvements are actually working. While claims processing technology can do much of the heavy lifting, it isn't a set-it-and-forget-it solution. Long-term success depends on constant fine-tuning. Organizations that stay engaged and monitor key metrics closely are better positioned to reduce denials, accelerate payments and improve financial outcomes. Experian Health consultants are also available to help guide these efforts, offering expert support and strategic advice to help claims processing teams get the most out of their investment. Find out how Experian Health's claims management tools help organizations take control of claims processing in healthcare for cleaner claims, fewer denials and faster reimbursement. Learn more Contact us

Claim denials are skyrocketing, and so are revenue cycle leaders' stress levels. In our most recent State of Claims survey, 54% of respondents said their current claims technology is sufficient to address existing revenue cycle demands at their organizations. However, that number was 77% just two years ago. That's because denial management has long been a reactive strategy. Many organizations focus on addressing claim denials after services are rendered and information is sent to payers. However, this approach often leads to increased labor costs, delayed reimbursements, and a higher volume of denied claims. It's time for a paradigm shift towards claim denial prevention, a proactive strategy that addresses potential issues before they result in denials. To prevent claim denials, go on the defensive Jordan Levitt, Senior Vice President at Experian Health, sees it as playing defense. “We use a term called 'Perimeter Defense' - get the patient's information right on the front end, before it gets into the system,” says Levitt. “Denials are happening because incorrect or bad data gets in early, costing health systems time - and money – to fix on the back end. The mindset is moving from management to prevention.” The legacy denial management approach being used today involves significant manual intervention, including correcting errors, resubmitting claims, and appealing denials. The result is a costly and time-consuming process that diverts valuable resources from more strategic tasks. Denial prevention, on the other hand, focuses on addressing potential issues at the front end of the revenue cycle. By ensuring that claims are accurate and complete before they are submitted, organizations can significantly reduce the volume of denied claims. This proactive approach not only accelerates cash flow but also reduces the burden on billing staff and lowers contingency vendor fees. Bad patient data is like a virus “There's a revenue cycle adage often referred to as 'Know Thy Patient,'” says Levitt. “With the Denial Prevention philosophy, at registration and scheduling we need to know exactly who they are (e.g. John Smith or Jonathan Smith?), where they live, and how to reach them, in addition to all of their coverages, the order of billing - everything.” The inherent problem today, he continues, is that the first time incorrect or outdated patient data is ingested into a health system, it proliferates throughout the entire system. Electronic health records are great at keeping patient data together for a health system, but they don't distinguish between good data and bad data. It's all just data. “Whether a patient is coming by way of a physician's office, a business office or residence and the information is wrong, it populates throughout an integrated system - hospitals, urgent care, labs,” says Levitt. “Once you let bad data in the door, regardless of the origination point, it's like a virus. Each time that happens and you're building the work queues and you're building buckets of contingency funds if you can't solve it at the start of the process. Every action you take once bad data enters your system is wasting resources.” Fixing poor data on the front end is the key to preventing claim denials That seems like an obvious solution. However, throwing more people at the problem isn't the right answer when technology that is faster, more accurate and fully integrated into workflows is available. Solving for incorrect or missing eligibility, insurance coverage, Medicare Beneficiary Identifier (MBI), demographics and continuation of benefits is readily available with just a simple click. Experian Health's Patient Access Curator is a robust revenue cycle solution designed to prevent claim denials at the front end. It addresses bad data quality with real-time data correction, performing eligibility checks, coordination of benefits (COB), Medicare Beneficiary Identifier (MBI), demographics, and discovery in a single solution. With a single click, Patient Access Curator ensures quick, accurate registration and scheduling, significantly reducing denial volumes and billing errors, including: Eligibility Verification: Automatically interrogates 271 responses to indicate any secondary or tertiary coverage data. Coverage Discovery: Works behind the scenes to minimize the cost of insurance discovery and streamline workflows, often generating additional insurance revenue missed by previous processes. MBI Correction: Continuously finds and corrects MBIs using artificial intelligence (AI), in-memory analytics, and robotic process automation. Demographic Updates: Automatically identifies obsolete or inaccurate data using proprietary algorithms. COB Analysis: Analyzes each payer response in real-time at the point of service and integrates directly into the eligibility verification process. Benefits of claim denial prevention By successfully transitioning to a denial prevention strategy, revenue cycle teams can: Reduce denial volumes: By addressing issues before claims are submitted, organizations can significantly reduce the volume of denied claims. Lower labor costs: Automation and real-time data correction reduce the need for manual intervention, allowing staff to focus on more value-added tasks. Accelerate cash flow: Faster, more accurate claims submission leads to quicker reimbursements and improved cash flow. Enhance patient satisfaction: Accurate and timely claims processing reduces the need for patient follow-up and improves overall patient satisfaction. Beyond denial management: The strategic shift to claim denial prevention The transition from claim denial management to denial prevention represents a significant shift in how healthcare organizations approach revenue cycle management. By focusing on proactive strategies and leveraging advanced technologies like Patient Access Curator, organizations can reduce the burden of denied claims, lower costs, and improve overall efficiency. Embracing denial prevention is not just a strategic advantage—it's a necessity in today's complex healthcare landscape. Watch the video to see how Patient Access Curator is evolving patient access at light speed, using the power of AI and machine learning.  Learn more about Patient Access Curator and contact us to see if you qualify for a free denial analysis. Learn more Contact us

Revenue cycle management (RCM) leaders feel it every day: financial pressures continue to mount, with hospital and laboratory operating margin compression becoming a challenge for even the most financially sound healthcare organizations. To combat claim denial pressures and strained lab and hospital profit margins, healthcare providers should start with the beginning in mind. Strained lab and hospital profit margins are particularly evident in revenue cycle operations, where every dollar billed to a payer needs to find its way back to the system. Rising labor costs, increased expenses for purchased services, and declining patient demand - plus inflationary pressures and labor shortages - have exacerbated these issues. As a result, many hospitals and health system leaders are struggling to maintain financial sustainability. The best revenue cycle leaders must deftly navigate a complex mix of denial management strategies and AI-based technology, like Patient Access Curator, to maximize revenue and improve operational efficiency. Payers aren't helping lab or hospital profit margins Payers, facing their own financial pressures, are tightening hospital operating margins even further, leading to increased claim denials, hyper-focused audits, and reduced reimbursement rates. These strategies create a series of cascading challenges for RCM teams, including increased administrative burdens and revenue leakage. According to a report by Healthcare Finance, 84% of health systems cite lower reimbursement from payers as a top cause of low operating margins. Additionally, 82% of CFOs have seen a significant increase in payer denials since pre-pandemic levels. Higher labor costs are another major driver of margin pressure, with 96% of CFOs reporting this as a significant issue. Healthcare leaders agree – strained profit margins are an ongoing struggle In Experian Health's own research, healthcare executives identified strained profit margins as their biggest challenge. The underlying struggle is about money—keeping cash flowing and supporting a healthy organization. One of the country's top health system CFOs stated that it's the first time in his 30-year career where his beds are full, but he has zero margin. This highlights the severity of the issue. Jason Considine, President at Experian Health, says, "We talk to healthcare leaders frequently and our survey and polling have revealed their primary concerns leading to strained margins – and a highly-pressured financial environment. Some of these reasons might be front and center [for a particular organization], others secondary or tertiary. But all of them are driving down margins across health systems: inpatient revenue erosion, cost of labor, rising staffing and supply complexity, delayed payer reimbursements, regulations, and a very fluid, shifting payer mix. It's consistent from system to system, hospital to hospital." Quick fixes only deepen the problem How have most healthcare organizations been playing catch-up? They throw various fixes at the problem, like cobbling together denial management teams, and adding more software, contingency vendors, and labor. However, those solutions can be a knee-jerk reaction, and only compress margins further. Take a look at coordination of benefits (COB) denials. Revenue cycle leaders often don't have the complete data picture when they look at a 271 response to establish primacy and ignore the “noise” of secondary or tertiary payers. Many don't truly know their system's current process for COB denials – nor that of the vendors or staff who try to 'fix' the problems. Bud Zuberer, VP of Sales at Experian Health, says, "On a daily basis we hear that COB denials, contingency fees, and labor costs are crippling revenue cycle teams. They're paralyzed with too many decisions to make. This collection of problems has led to a rise in denial management teams and personnel. We're witnessing the invention of companies to 'solve' the problem. But that's not the answer. The answer lies in ensuring the data ingestion is correct from the start.” Adding more solutions or software to an already full slate of vendors can also be problematic, as it requires more human touchpoints and capital investments. Ultimately, this affects cash flow, cash acceleration, and days in accounts receivable (AR). Prevention is the best medicine to improve strained lab and hospital profit margins The fastest way to ease the pain of rising claim denials and falling cash flow is denial prevention – fixing downstream problems upstream, before they occur. As Zuberer points out, clean data from the start will reduce denials and chasing cash on the back end. Experian Health's all-in-one Patient Access Curator prevents claim denials in seconds by solving bad data quality and real-time data correction, drastically cutting contingency vendor fees and accelerating cash flow. Some of the key benefits of Patient Access Curator include: Reducing billing errors: Artificial intelligence (AI) and machine-learning guided technology improve claim and data accuracy. Quick, accurate patient registration and scheduling: Streamlines processes. Lower denial volumes: Prevents claim denials at the front end. Decrease human resources related to denial management: Eases staffing shortages and frees up team members for higher-value tasks. Client success story Exact Sciences, one of the largest laboratories in the U.S., recently began using the Patient Access Curator in its revenue cycle operations. Thanks to Patient Access Curator, Exact Sciences achieved the following results: 15% increase in revenue per test due to accurate eligibility and fewer denials 4x business volume without increasing headcount 50% reduction in denials and major improvement in timely filings $100 million added to the bottom line in 6 months “You know when Patient Access Curator went live because you can see it in our stock price. It helped us drive a $100 million bottom-line improvement within two quarters.” - Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences Read the full case study or see what Kubisty had to say in a new testimonial: Prevent strained profit margins in the long run  Strained profit margins are a significant challenge for healthcare organizations, impacting revenue cycle operations and overall financial health. By adopting strategic approaches and leveraging technology, healthcare leaders can navigate these complexities and confirm every dollar is accounted for. In this evolving landscape, proactive and adaptive leadership is crucial for sustaining financial stability and delivering high-quality care. Learn more about how Patient Access Curator helps prevent strained lab and hospital profit margins by solving for bad data, all at once. Patient Access Curator Contact us

“Enhanced Claim Status will provide you with more information extracted directly from the payer site that you will not get in a regular claim status.”—Jake Reid, Senior Director of Revenue Cycle Business Offices at St. Luke's Health System Challenge St. Luke's Health System is Idaho's largest healthcare provider, handling over three million outpatient visits per year and processing more than 450,000 claims per month. As the organization grew, rising patient volumes put pressure on staff to keep billing processes running smoothly. They needed a scalable solution to manage claims follow-ups without increasing headcount or compromising patient care. “We had a growing population and an increase in accounts receivable (AR),” says Jake Reid, Senior Director of Revenue Cycle Business Offices at St. Luke's. “We couldn't keep up. To continue to fulfill our mission to support our communities and stay financially sound, we needed a more efficient way to collect revenue.” They focused on four key questions: How can we maximize staff efficiency by improving post-claim follow-up? How can we leverage technology to handle growing account volumes without increasing headcount? How can we avoid wasted touches so staff can focus on accounts that require follow-up? How can we accelerate AR recovery to improve cash flow and reduce aging? Solution After exploring in-house and outsourced options, St. Luke's decided to implement Experian Health's Enhanced Claim Status to automate and streamline the claims follow-up process. The tool pulls adjudication data directly from payer sites and delivers detailed claim statuses within Epic, eliminating the need for staff to manually track claims through payer portals or wait for remittances. What started as a pilot with just one payer quickly expanded to include other high-impact payers. The team liked how Enhanced Claim Status provided real-time insights into denied, rejected and pending claims, so they were able to prioritize and resolve issues sooner. Claims are automatically routed into work queues based on customized rules, accelerating follow-up by one to two weeks. This allowed staff to focus on the right accounts and reduced unnecessary work. Reid says, “Enhanced Claim Status will provide you with more information extracted directly from the payer site that you will not get in a regular claim status.” The team values this richer data, which includes enhanced data like proprietary reason codes and actionable explanations for each claim. St. Luke's worked closely with Experian Health to ensure all necessary fields were captured from payer responses and set up for payers not already supported, so no claims were overlooked. They were able to set their own rules for status checks, retry intervals and cutoff points, and claim status codes were categorized to determine the most appropriate work queue, based on St. Luke's own requirements. All payer responses are automatically formatted in a consistent way, so staff can continue to work efficiently, no matter how many new payers are added. Read the blog: 6 steps to improving the claims adjudication process Outcome Shifting to automated claim status checks significantly reduced the administrative burden, achieving the following financial results: Denials dropped by 76%, falling from 27% to just 6.5% since 2017 “Discharged/not billed” accounts were reduced by $15 million per month Hospital billing aged over 90 days now consistently meets Epic's Silver or Gold benchmarks, with the watch list down from an average of $13 million to under $1 million since going live in 2019 Patient billing over 90 days now sits at just 4.5%, putting St. Luke's among the top performers of Epic users Automation also helped St. Luke's save the equivalent of three full-time staff each year. With fewer unbilled accounts and more efficient workflows, the overall cost to collect went down. Staff appreciated having better data and more time to focus on complex accounts, which increased their capacity to support patients directly. Reid says that with Enhanced Claim Status, the organization has successfully achieved its goal of accelerating AR resolution and denials management, without overburdening staff. He attributes this to continuous testing, improvement and close collaboration with Experian Health: “Much of our success came from customizing the build to our workflows and processes. You will lose momentum and staff buy-in if you don't ensure the build is solid. The importance of testing cannot be underestimated. Finally, ensure you are checking in with Experian often to address any issues that arise. Experian has always been very responsive to my teams and I'd expect that to be the same for you.” Find out more about how Enhanced Claim Status accelerates claim follow-up and improves cash flow. Learn more Contact us