Claims & Contract Management

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

What happens when payers and providers interpret contract terms differently? Or revenue cycle teams miss critical details buried in the fine print? Contracts between healthcare providers and payers are supposed to make each party's responsibilities crystal clear. In reality, that isn't always the case. Hospitals face costly consequences if they fail to comply with payer policies, yet often struggle to monitor payment accuracy when it comes to being paid on time and in full. That's why good contract management matters. Ensuring both parties are reading from the same page protects providers from unmet expectations and revenue loss. As Timothy Daye, Director of Managed Care Contracting at Duke Health Integrated Practice, puts it, “It's about getting paid correctly per your contracts, so you don't leave money on the table.” With increasing pressure to manage costs, hospitals are rethinking how they manage contracts. This article looks at why a more strategic approach – built on contract management software – is essential. Why hospitals need a contract management system Medical plans receive around three billion claims each year, according to the latest CAQH index report. At that scale, even small discrepancies in contract terms can have a major financial impact for providers seeking reimbursement. In Experian Health's 2024 State of Claims survey, 73% of providers said claim denials were increasing, while 77% were seeing more frequent amendments to payer policies. These changes can catch providers off guard, especially when contract terms aren't clearly documented or regularly updated. For hospitals, the challenges in managing payer contracts include: Complex negotiations: Providers handle thousands of contracts with multiple plans and provisions, all subject to changing regulations. Without proper oversight, managing these negotiations can be time-consuming and overwhelming. Limited data analysis and outdated processes: Effective contract management depends on accurate, up-to-date data. Yet many organizations still rely on poorly defined manual systems that lack the analytics and real-time insights needed to evaluate contract performance, forecast revenue or support strategic decision-making. Conflicts over claim denials: Underpayments and denials are among providers' biggest challenges, with payers reportedly initially denying 15% of all claims. Disputes over claims, payments, and contract interpretations strain relationships and disrupt revenue cycle performance. A robust contract management system, using purpose-built software, brings structure to the negotiations and helps build effective and transparent working relationships with payers. Some of the benefits include: 1. More accurate reimbursements and fewer underpayments Automated oversight of payer contracts makes it easier to find discrepancies between the amounts billed and the rates agreed in payer contracts. Contract management software helps providers avoid missing out on reimbursements because of buried contract clauses and supports contract-based appeals to recover underpayments. 2. Better terms and stronger relationships with payers Contract management software for hospitals allows revenue teams to evaluate contract results and use that information to assess proposed terms for new contracts. This puts providers on a stronger footing in negotiations and allows them to agree to more favorable terms. More effective communications and quicker dispute resolution also improve provider-payer relationships. 3. Faster, more efficient workflows at scale Finally, automated workflows combine more accurate data to process claims faster, leading to a more predictable revenue cycle. They also lower administrative costs and allow staff more time to prioritize other patient-facing and revenue-building activities. Key features of hospital contract management software Not all solutions offer the automation, data or expert support to make the above benefits a reality. Experian Health's Contract Manager delivers all three. Here's how it works: A team of contract analysts assesses the organization's contract terms, fee schedules and payment policies to clarify what's required and when. Accurate rates and authorization rules are populated automatically to minimize pricing errors and reduce manual effort. Contract mapping and claim valuation logic reduces the risk of audits and penalties, while automated alerts help providers ensure their contracts comply with current healthcare regulations. Configurable online dashboards give staff immediate access to reimbursement reports, so they can compare expected and allowed amounts and monitor performance. Unlike manual systems, contract management software can be easily scaled for organizations of any size. Because it integrates seamlessly with existing hospital information and practice management systems, Contract Manager can audit claims for a medical group or a large health system with one solution. When paired with Contract Analysis, healthcare providers get added negotiating power by getting the data needed to assure terms that optimize reimbursement.  Discover how Experian Health's Best in KLAS Contract Manager solution helped Boston Children's Hospital resolve underpayments, work with payers to resolve issues and errors, and more. Choose the right hospital contract management software Managing payer agreements may not be the most visible part of the revenue cycle, but its impact is significant. Minor contract discrepancies can quietly erode margins. As providers work to control costs while maintaining care quality, hospital contract management software has become critical in securing fair reimbursement rates and auditing payer contract performance with confidence. Providers should choose a solution that allows them to verify payment accuracy, resolve disputes faster and prevent lost revenue through unnecessary claim denials. The solution should also deliver real-time visibility into contract compliance and reimbursement trends so revenue cycle teams can stay ahead of policy changes and protect margins. Experian Health's Contract Manager and Contract Analysis solution continuously audits payer contract performance and applies current reimbursement rules for Medicare and other payers, for the most precise pricing. It ensures staff have accurate data to hand to conduct contract-based appeals and communicate clearly with payers. For these reasons, Contract Manager was named Best in KLAS in 2025. It's a proven choice for hospitals seeking to reduce revenue leakage and strengthen payer relationships at scale. Find out more about how Experian Health's hospital contract management software helps providers take control of reimbursement and protect their long-term financial health. Learn more Contact us

Early diagnostics, remote patient monitoring and personalized care recommendations are just a few examples of how artificial intelligence (AI) is transforming the way healthcare is delivered. As technology advances, so do opportunities to optimize clinical and operational processes. With projected savings in the region of up to $360 billion annually, it's no surprise that 75% of healthcare executives believe AI has reached a turning point in their industry. Yet many providers are still just scratching the surface. Only a small percentage use AI for complex tasks like claim denial management, leaving the competitive advantage wide open. Understanding how these technologies work – and where to apply them for maximum impact – will be crucial to improve efficiency, remain competitive and above all, deliver excellent patient care.  The power of AI in healthcare As the name suggests, artificial intelligence refers to a machine's ability to perform cognitive tasks that would normally be associated with humans, such as problem-solving and decision-making. It can spot patterns, learn from experience and choose the right course of action to achieve a goal. Natural language processing, robotics and machine learning might all be in the mix. AI in the healthcare industry has been found to support applications like: Improving diagnosis through the analysis of medical images AI-powered wearables and virtual nursing assistants Patient data management Reducing and preventing insurance claim denials. Artificial intelligence in healthcare isn't a substitute for human contact, which underpins the best patient care. However, by increasing accuracy and reducing costs, it can help clinicians and healthcare administrators make better decisions that support a positive patient experience across virtually all healthcare settings. AI & automation in healthcare: key benefits  AI and automation deliver results in the three areas that matter most to healthcare organizations: improving the patient experience and care delivery, allowing staff to perform at their highest level, and increasing revenue. Boosting patient satisfaction through speed and accuracy Patient feedback has a few common themes: timely access to care, clearer communication and greater financial transparency. To meet these needs (and improve those feedback scores), healthcare providers should offer patients accurate, upfront information and reduce friction wherever possible. Tools like Patient Access Curator use AI to verify and update all necessary patient information at the front end, all at once, which drastically reduces the time and effort required to manage patient records. This streamlines patient intake and solves for bad data, which prevents claim denials and increases patient satisfaction. Bringing in more revenue by reducing claims errors The 2024 CAQH index estimates that 22% of current costs could be saved by shifting from manual revenue cycle processes to automated ones. Experian Health's State of Claims Survey 2024 suggests providers are eager to capitalize on this opportunity, with 51% seeking to reduce manual work. AI-driven solutions like Patient Access Curator and AI Advantage are designed specifically to meet these needs. Patient Access Curator automates insurance eligibility and coverage, scanning patient documentation for inaccurate information, and uses AI and robotic process automation to reduce manual errors. AI Advantage™ works to prevent denials before they happen, using predictive analytics to flag claims errors and alert staff to claims that fail to meet payer requirements. Improving staff performance by easing burnout The strain of manual processes doesn't just slow down operations. It's also a major cause of staff stress and burnout. Around half of healthcare staff report feeling burned out, costing the industry an estimated $4.6 billion each year. By taking repetitive tasks off busy employees' plates, AI can alleviate overwork and allow staff to focus on higher-value work, improving job satisfaction and productivity. In claims management, for example, AI Advantage, works in conjunction with ClaimSource®, to proactively identify claims with a high likelihood of denial prior to claim submission without staff intervention. This reduces the burden on staff while improving clean claim rates. How AI Advantage and Patient Access Curator improve patient care Experian Health's two flagship AI-based products go even further, offering new ways to use technology to improve patient care: Patient Access Curator uses AI and robotic process automation to streamline one of the most tedious parts of patient intake – verifying insurance eligibility and coverage. By automatically scanning patient records for errors and pulling up-to-date information from payer sources, it eliminates the guesswork and manual labor that bog down revenue cycle teams. The result is faster, more accurate eligibility verification and a smoother experience for both staff and patients. As Ken Kubisty, VP of Revenue Cycle at Exact Sciences, put it: “Within the first six months of implementing the Patient Access Curator, we added almost 15% in revenue per test because we were now getting eligibility correct and being able to do it very rapidly.”  On the back end, AI Advantage – Predictive Denials acts as an early warning system for denials, scanning claims before they go out the door to catch errors and flag risky submissions so they can be corrected in time. Built on advanced AI and machine learning, the platform evaluates claims using historical payment data and real-time payer behavior. Its counterpart, AI Advantage – Denial Triage, picks up where Predictive Denials leaves off, sorting rejected claims according to their potential for reimbursement and prioritizing them based on financial impact. Together, they help providers minimize denials, resulting in faster reimbursement and freeing up resources that can be redirected to patient care. Case study: See how AI Advantage helped Schneck Medical Center achieve a 4.6% average monthly decrease in denials in the first six months. The future of AI in healthcare: what's next? As a quick glance at any newsfeed will confirm, AI's role in healthcare is only going to expand. Predictive analytics will give staff increasingly powerful insights and recommendations to maximize reimbursements, while minimizing the burden on the workforce. AI's ability to continually learn and improve means providers that embrace AI will be better placed to make full use of their data and adapt to the trends and challenges that affect patient care. As expectations grow and resources shrink, AI is likely to be the only way to deliver the scalable, responsive, high-quality care patients deserve. Discover how solutions like AI Advantage and Patient Access Curator use artificial intelligence in healthcare to help reduce claim denials, improve patient access and more. AI Advantage Patient Access Curator

Experian Health's State of Claims survey finds that for many providers, it's getting harder to submit clean claims and taking longer to get paid. More than half say their current technology can't keep up. With revenue at risk, choosing the right denial management software is increasingly important. What features should healthcare organizations look out for to prevent denials and improve financial performance? Why denial management software is essential 11% of respondents in the State of Claims survey said that claims are denied more than 15% of the time, while the administrative cost of submitting and reworking claims continues to rise. Revenue cycle leaders are all too familiar with the challenges driving the denials trend: Frequent updates to payer policies, which make it harder for staff to be sure their submissions comply with the latest rules Incomplete or inaccurate data, such as missing codes or demographic errors, Staffing shortages put pressure on overworked teams, leading to higher error rates and slower response times Reimbursement delays, which tie up revenue and increase the cost of follow-up. Managing these issues is time-consuming and expensive. Speaking to the AAPC, Clarissa Riggins, Chief Product Officer at Experian Health, says that without a robust denial management strategy, providers risk falling further behind. “This growing crisis is a sign that traditional approaches are no longer enough, and providers should adopt more proactive strategies and the latest technology,” she says. Denial management software can help. By automating error detection, tracking payer requirements and helping staff prioritize high-risk claims, it can reduce denials and strengthen overall revenue cycle performance. According to the CAQH, just switching from manual to digital claim submission could save the industry up to $2.5 billion annually. Artificial intelligence (AI) and machine learning, used in solutions like AI Advantage™, can take those savings even further. Key features to look for in denial management software To make a real impact, healthcare denial management software must do more than just track denials. The best solutions offer faster responses, deeper insights and greater efficiency across the revenue cycle. Here are a few core features to seek out: Real-time claim monitoring Does the software alert users the instant a claim is denied? Real-time claim status updates are critical for minimizing delays and missed follow-ups. Automated alerts allow teams to act immediately when a claim is denied, preventing lost revenue and streamlining appeals before a backlog builds up. Tools like AI Advantage can also automatically detect payment pattern changes made by payers, so billers don't have to. Automated workflow  Can it reduce time spent on repetitive manual tasks? Ideally, the software will streamline submissions by auto-populating forms, attaching documentation and routing tasks to the right team members. This minimizes errors, shortens appeal cycles and frees up staff for higher-value tasks. Artificial intelligence Can the platform use AI to prevent denials before they happen (and prioritize the ones worth pursuing)? Experian Health's AI Advantage does this in two ways. First, it uses AI to analyze historical trends to flag high-risk claims before they're submitted, helping teams correct issues early and prevent denials altogether. Second, it identifies denials with the highest chance of a successful appeal, so staff can prioritize their time and improve overall recovery rates. Watch the webinar: Eric Eckhart of Community Regional Medical (Fresno) and Skylar Earley of Schneck Medical Center share how AI Advantage has helped them reduce denial volume, accelerate reimbursement and reduce time spent working low-value denials. Analytics and reporting Does it provide clear insights into why claims are denied? Advanced analytics identify denial patterns across payers, procedures and departments. A tool that offers denial-specific performance indicators, like denial rate, overturn rate and days to resolution will support smarter, faster decisions and long-term process improvements. Keri Whitehead, System Director of Patient Financial Services at UC San Diego Health, explains how AI Advantage gives her team actionable insights to get ahead of denials: Integration capabilities Can it connect seamlessly with current systems? A strong denial management platform should integrate smoothly with electronic health records, practice management systems and billing software. This eliminates data silos, reduces manual data entry and allows staff to work within familiar workflows. Experian Health's “Best in KLAS” claims management solutions can be used to build a single, connected system for greater visibility, fewer duplication errors and faster processing, to prevent denials without adding administrative overhead. Steps to evaluate denial management software Choosing the right claim denial management solution starts with a clear understanding of the organization's unique challenges and goals. Healthcare leaders should consider the following steps during the selection process: Define organizational needs. Identify the most pressing denial challenges, such as high denial rates, slow appeals or limited visibility, and prioritize software that directly addresses those issues. Evaluate integration compatibility. Confirm that the software integrates smoothly with existing systems to avoid data silos or workflow disruptions. Assess scalability. Ask potential vendors about how the solution will grow with the organization and adapt to changing claim volumes, payer mixes and regulatory demands. Review vendor support and training. Look for a partner that offers responsive support, user training and ongoing product updates. Request a demo or trial. The best way to figure out if a new platform will be a good fit for the organization is to see it in practice and let key team members try out its automation, interface and analytics for themselves. Book a demo of AI Advantage to see how it can help providers predict and prevent denials. Best practices for implementing denial management software Once the denial management software has been chosen, the final step is to make sure it's implemented successfully. This calls for good planning, team buy-in and ongoing evaluation. A few best practices to steer the process are to: Engage core teams early to ensure the software fits with their existing workflows and organizational goals. Make sure there's a shared understanding of what success looks like, using KPIs like denial rate reduction or faster appeals to measure performance and ROI. Provide thorough training to equip staff with the skills needed to use the system effectively. Regularly review software performance, denial trends and user feedback to refine processes and settings. By following these steps, organizations can maximize the impact of their new healthcare denial management software and turn a reactive process into a strategic advantage. Find out more about how Experian Health's denial management software, like AI Advantage, helps providers predict, prevent and process denials for faster revenue recovery. Learn more Contact us

Medical billing errors are common problems that can lead to significant financial losses for healthcare organizations. While most medical billing errors are preventable, outdated systems, complex processes and human errors often result in delayed or denied claims. Faced with ever-increasing overhead costs, workforce challenges and growing volumes of data, healthcare leaders will need to implement modern medical billing software solutions to improve revenue cycle management (RCM) medical billing efficiencies, without adding costly headcount or overhead. This article reviews the role modern medical billing software plays in revenue cycle management and how RCM leaders can use it as a top defense to prevent costly claim delays and denials. What is medical billing software in revenue cycle management? Medical billing software is a critical tool healthcare organizations use to streamline patient billing and collections in revenue cycle management. Revenue cycle leaders know that outdated and complex billing processes can wreak havoc on the entire revenue cycle and waste valuable staff time. However, medical billing in revenue cycle management allows providers to optimize the entire revenue cycle — from pre-visit insurance verification and cost estimates through patient billing and collections. Automated medical billing processes in the revenue cycle can help improve efficiencies, reduce errors, and create more reliable collections processes. This allows healthcare organizations to deliver better patient care while protecting their bottom line. How software powered by artificial intelligence (AI) improves medical billing efficiency AI-powered software helps providers manage many types of complex revenue cycle billing processes — from claims management to collections. Providers that embrace AI often benefit from streamlined medical billing processes, fewer claim denials, real-time eligibility verification, better data insights and productivity boosts. For example, AI-powered software can streamline medical billing by automating repetitive tasks, like insurance verification checks, so providers can prevent and catch errors, speed up reimbursements and stretch strained resources. On the front end, with single-click AI-driven data capture technology, running multiple manual eligibility queries is no longer necessary. Now, with solutions like Patient Access Curator, patient details can be verified quickly and accurately. Patient Access Curator leverages AI and machine learning to automatically handle eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, insurance discovery and more, with just one click. This saves staff hours and reduces human errors that can lead to claims denials and costly delays later on. Ken Kubisty, VP of Revenue Cycle at Exact Sciences, shares how Patient Access Curator helped their organization reduce claim denial errors and added $75 million in insurance company collections. AI-driven predictive analytics solutions, like AI Advantage™, can also help staff identify claims that may be at risk of denial, so potential issues can be handled before submission — saving even more staff time. When admin overhead is minimized, there's less burnout and less stress. Staff can focus on higher-priority tasks, and healthcare organizations can see productivity increase overall. Preventing claims denials with better billing solutions Claims denials are on the rise with healthcare organizations being left on the hook for delayed or unpaid claims. In the State of Claims 2024 report, 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of cost in reworks and lost revenue. Nearly half of providers say patient information errors are a primary cause of denied claims. Errors are common during pre-visit insurance verification due to error-prone manual processes, but can happen at any point during the collection process. Medical billing software helps providers reduce errors and submit cleaner claims right from the start and catch errors before they become costly problems. Here are some of the key ways medical billing software like Experian Health's Patient Access Curator solution helps providers head off claims denials before they happen.   Eligibility checks: Automatically verifies patient eligibility and updates records in real-time to ensure patient information is accurate before claims submission. Coordination of Benefits (COB) verification: Discovers and verifies secondary and tertiary insurance coverage to reduce the risk of COB-related denials while using AI-powered technology to seamlessly integrate with a provider's eligibility verification process. Medicare Beneficiary Identifiers (MBIs): Updates MBIs to confirm patient records are correct and compliant with Medicare requirements while using AI-driven technology and automation to find and correct patient identifiers automatically. Demographics: Patient demographic information is corrected and updated using in-memory analytics and Experian Health's proprietary algorithm to accurately find and fix contact information. Insurance Discovery: Identifies and corrects missing or incorrect insurance information to ensure claims are submitted with the most accurate information available. Discover how Experian Health's revolutionary AI-powered revenue cycle solution is turning denial management into denial prevention. Patient Access Curator solves for missing or correct data in real-time at registration and scheduling, creating a smooth, clean claim process and lowering denials by double digits. Optimize efficiencies in claims management through AI Experian Health customers currently using ClaimSource® can now improve their claim management strategy — before claim submission and after denial. With AI Advantage™ Predictive Denials and Denial Triage, providers can leverage historical claims data and Experian's deep knowledge of payer rules to continuously adapt to an ever-changing payer rules landscape.AI Advantage's - Predictive Denials component reduces denial rates, detects payer changes and empowers staff to focus on highest-priority claims, while AI Advantage's - Denial Triage identifies denials with the highest reimbursement potential and uses AI to segment denials, eliminating guesswork for billers. Watch the video to learn more about the two components that make up AI Advantage, and how healthcare organizations can transform the reimbursement process and decrease claim denials for good. Medical billing software is only getting smarter and faster Upgrading outdated manual medical billing processes results in cleaner claims, improved staff efficiencies, better care and improved patient satisfaction. Today's AI-driven technology brings medical billing in RCM to the next level, enabling time-strapped providers to do even more with less. Now busy providers can streamline manual processes that used to take hours into just seconds. With this new technology, patient information is accurate when claims are submitted, eliminating the need for costly reworks and hits to the bottom line. As more providers adopt AI technology for RCM in medical billing and software solutions get more sophisticated, providers will see new success stories in its power to help healthcare organizations optimize the entire revenue cycle. Learn how tools like Patient Access Curator and AI Advantage can help healthcare organizations prevent claim denials and improve medical billing in RCM. Learn more Contact us

Providers and payers have an obligation to fulfill contractual obligations to one another. However, mistakes happen, and when they do, they can be costly. More and more, providers are turning to healthcare contract management technology to ensure accountability, protect against revenue losses and streamline efficiencies – all while improving the relationship between providers and payers. Finding the right contract management solution (and technology partner) is critical for contract managers who want to meet the challenges of today and tomorrow head-on. This article explores how healthcare organizations can benefit from adopting contract management technology and key features to look for when choosing a contract management solution. Understanding healthcare contract management Healthcare providers need reassurance of proper reimbursement, while payers are focused on cost control. Healthcare contract management encompasses the many processes providers use to negotiate, execute and audit payer contracts. As services (and financing) evolve in complexity, contract management helps providers and payers avoid costly disputes and maintain effective working relationships. A robust contract management system in healthcare quickly and efficiently pinpoints potential issues to ensure providers are paid per contract terms and payment policies — maximizing revenue recovery. Challenges in managing healthcare contracts Managing healthcare contracts can be complicated. Key challenges in healthcare contract management often include: Complex negotiations: Managing thousands of contracts with multiple plans and provisions can be time-consuming and overwhelming, especially with ever-evolving regulatory requirements. Limited data visibility: To evaluate contract terms effectively, contract managers need to factor in performance data for existing contracts and current figures for patient mix and volume, which can be challenging when accessing the right data and models is difficult. Claim denial conflicts: Payers reportedly deny 15% of all claims initially. When claims are denied, it can lead to disputes over payments and contract interpretations, straining relationships and disrupting revenue cycle performance. Inefficient processes: Disjointed paper processes, manual systems and miscommunications often lead to errors, delays and wasted dollars during contract management. Benefits of healthcare contract management technology Healthcare organizations that embrace contract management technology typically see the following benefits: Maximized revenue recovery Contract management software, like Experian Health's Contract Manager, increases revenue by validating reimbursements and reducing underpayments. Through automated oversight of payer contracts, providers are easily able to validate reimbursement accuracy by comparing expected allowed amounts to actual allowed amounts. Contract Manager also pinpoints variances buried in contract clauses, so providers avoid missing out on potential reimbursements, and provides support for contract-based appeals to recover underpayments. Stronger contract negotiations (and relationships) Contract management technology allows providers to evaluate existing contract results and use that information to assess proposed terms for new contracts. As a result, providers are empowered to negotiate stronger terms with payers. Improved contract negotiations often mean more effective communication and quicker resolutions, too, leading to stronger provider-payer relationships. Improved workflow efficiencies Automated workflows in contract management software combine data to process claims faster and at scale. This translates to a more predictable revenue cycle, improved cash flow and lower administrative costs. Instead of managing contracts, staff are freed up to focus on patient care and revenue-building activities. Hear how Experian Health's Contract Manager solution helped Boston Children's Hospital resolve underpayments and collaborate with payers to ensure every dollar is recovered. Key features to look for in contract management solutions Contract management technology helps healthcare providers stay ahead of some of the key challenges in healthcare contract management. Key features to consider in contract management solutions include: Scalability: Flexible single solution that enables users to easily audit claims across an entire organization – whether one medical group or a large health system. Automation of manual tasks: Accurate authorization rules and rates are automatically populated to reduce manual effort and potential errors. Real-time reporting: Configurable online dashboards that provide staff with immediate access to reimbursement reports to monitor contract performance and quickly compare expected and allowable amounts. Contract analyst team: Dedicated contract analysts assess the provider's contract terms, fee schedules, carve-outs and payment policies. Regulatory compliance: Built-in features, like contract mapping and claim valuation logic, that reduce the risk of audits and penalties, plus automated alerts to help providers make sure contracts remain with current healthcare regulations. Watch the webinar: Hear how OrthoTennessee used Contract Manager to validate reimbursements, pursue bulk appeals and recover underpayments at scale. Future trends in healthcare contract management As providers grapple with continued complexities in contract management, regulatory shifts and staffing shortages, contract management technology will likely remain an important tool for providers that want to level the playing field. Providers can benefit from choosing innovative solutions that help them stay ahead and do more with less – like Experian Health's Best in KLAS award-winning Contract Manager. Clarissa Riggins, Chief Product Officer at Experian Health, says, “In the ever-evolving healthcare landscape, our Contract Manager solution has once again been recognized as the #1 Revenue Cycle Management tool by KLAS for the third consecutive year. This prestigious ranking underscores the significant value our solution delivers to our clients by identifying underpayments and facilitating revenue recovery. We are honored to continue supporting our clients with innovative solutions that drive financial success and operational efficiency.” Find out more about how Experian Health's contract management software for healthcare providers validates reimbursements, reduces revenue loss and strengthens relationships with payers. Learn more Contact us