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Upgrading claims technology was the top strategy for reducing denials in 2022, according to Experian Health’s State of Claims 2022 report. The report lists the most common strategies for minimizing the risk and impact of denials, based on a survey of 200 health professionals. With more than half of providers already embracing automation, there’s broad recognition that data-driven software and streamlined workflows are key to getting more claims approved the first time and minimizing avoidable revenue loss. And as new AI-based technologies gain traction as a route to faster and richer data analytics, there are growing opportunities for providers to leverage automated claims management solutions and improve healthcare claims processing. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand the current state of claims management. Watch the video to see the results: Here are 4 ways to improve healthcare claims processing, based on current practice and perceptions of claims management, and the solutions that can help providers reduce denials in 2023. 1. Upgrade claims technology More than half of survey respondents (52%) updated or replaced existing claims process technology in 2022. Healthcare executives were optimistic about using more advanced automation to improve claims processing workflows, with more than 91% saying they would “probably” or “definitely” invest in automation over the next six months. The benefits of automating healthcare claims management are well-documented. Less friction and fewer errors lead to faster and more accurate submissions, so claims are more likely to be reimbursed. Tasks can be assigned to the right specialist to make more efficient use of staff time and alleviate pressure on busy teams. Artificial intelligence (AI) takes this up a notch with additional predictive capabilities and the ability to “learn” from historical claims data. Action: Prioritize automation of data-heavy, repetitive claims management processes and leverage AI to prevent denials Recommended tool: ClaimSource® helps providers manage the entire claims cycle by creating custom work queues so staff can prioritize the most valuable tasks and speed up reimbursement. Experian Health’s new AI Advantage™ solution integrates with ClaimSource to predict and prevent denials. Pre-submission, AI Advantage™ – Predictive Denials identifies claims that are at risk of being denied, so corrections can be made before claims are sent to payers. AI Advantage™ – Denial Triage comes into play post-submission, reviewing patterns in denials to prioritize those with the greatest likelihood of reimbursement. Together, these tools give staff the insights to reduce workload and minimize denials. Experian Health is pleased to announce that we've ranked #1 in Claims Management and Clearinghouse, for our ClaimSource® claims management system, according to the 2023 Best in KLAS: Software and Professional Services report. 2. Automate patient portal claims reviews For 44% of respondents, automating patient portal claims reviews were seen as an effective way to get claims right the first time. Patients can check for errors and inconsistencies in their own accounts, to prevent avoidable mistakes from ending up on claims submissions. Patients can also use portals to track the progress of claims, so they don’t need to speak to an agent. It’s more convenient for patients and reduces the call burden on staff. Action: Review digital patient access strategies to improve patient engagement Recommended tool: Safe and secure patient portals can facilitate better communication between patients and providers, smoothing out many common bumps in the claims management process. If it’s easier for patients to submit accurate and timely insurance, medical and contact information, it’ll be easier for providers to submit prompt, accurate claims. 3. Provide accurate estimates In 2022, 40% of respondents said they’d focused on providing accurate cost estimates to patients as a way of reducing claim denials. Patient estimates may not be the most obvious route to improving the denial rate, but they set the stage for successful claims management. If a provider can pull together all the necessary variables to produce accurate estimates, then they have all the pieces in place to submit clean claims. Other byproducts of reliable, upfront estimates can be seen throughout the revenue cycle: patients are more likely to pay their bills sooner and have better patient experiences. Action: Invest in pre-service patient estimates technology Recommended tool: Patient Payment Estimates allows providers to pull together complex data on each patient’s specific medical, coverage and financial circumstances into an accurate estimate of what the payer will cover and what the patient will have to pay. These accurate, upfront estimates not only improve the patient experience and make it easier for patients to understand and pay their bills, but also ensure the pieces are in place to support smoother claims management. 4. Digitize registration Finally, 39% of providers said they’d embraced digital patient registration in 2022 to tackle the problem of denials. As with patient estimates, this approach works by ensuring patient details are as accurate as possible from the start. Improving accuracy on the front-end prevents errors, delays and rework further on in the claims processing workflow. Digital and self-service registration also reduces the burden on staff. Many of the reasons providers gave for denials related to concerns around managing limited resources for everything from payer policy changes to patient admissions. Digital patient registration allows patients to complete patient access before they come in, so staff are freed up to focus on other tasks. Action: Implement an automated self-service patient registration solution Recommended tool: Registration Accelerator reduces reliance on time-consuming manual data-entry processes, which often result in denied or delayed reimbursements. Not only does it alleviate staff pressures and reduce labor costs, it also improves data quality. This solution integrates with existing health information systems, electronic medical records and eCARE NEXT®, which streamlines data entry. This will be key as providers look to reduce labor costs, increase efficiency and accelerate payments. Effective claims management requires speed, accuracy and flexibility. Find out how Experian Health’s automated claims management solutions can help providers improve healthcare claims processing and reduce denials.

Having the right health insurance eligibility verification software can make or break the healthcare revenue cycle. In fact, there's a direct correlation between the efficacy of an organizations' eligibility verification system and the amount of revenue the organization generates. If there are eligibility verification errors during the process, it can be more difficult to file claims and receive payments. 4 common insurance eligibility verification errors to watch out for: 1. Wrong or incomplete patient data Healthcare providers are responsible for verifying patient coverage. As part of the process, staff checks the patient's identity and contact information to confirm that it matches their electronic health records. Other important verification steps include confirming patient eligibility for proposed services, checking for exclusions and double-checking that the patient's coverage is not only active but that any annual or lifetime limits haven't been exceeded. But when a patient provides incorrect or incomplete information during the early stages of eligibility verification, it can bottleneck the entire verification process. Patients may have moved, switched employers or even switched their insurance coverage. When providers don't have access to the most up-to-date patient data, it can result in eligibility verification errors and create extra work for staff. Incomplete or wrong patient information not only makes the process more time-consuming but can also stall the claims process, resulting in delayed reimbursements or issues getting paid. 2. Incorrect insurance information Verifying a patient's insurance coverage is one of the earliest parts of the revenue cycle. And it can be complex, especially with patients frequently changing insurance providers and taking on more payment responsibility. While a patient insurance ID card is helpful, it doesn't prove eligibility. To verify eligibility, access staff will typically need to check payer websites or call payers directly. They also choose to use clearinghouses to run batch checks. But these options can be laborious and time-consuming. With the end of the COVID-19 public health emergency (PHE), it's also expected that up to 15 million Americans could find themselves without healthcare insurance, making the verification process even more tedious. The US Department of Health and Human Services (HHS) estimates that 8.2 million Medicaid enrollees will no longer be eligible for coverage. And another 6.8 million eligible individuals may lose coverage due to “administrative churn,” which occurs when patients fail to provide annual confirmation of Medicaid eligibility. These wide-scale changes to coverage could increase the risk of insurance information errors and longer verification checks, creating more stress and work for staff, claim denials, uncompensated care and millions in lost revenue. 3. Human errors lead to eligibility verification errors As the volume of patients continues to grow, providers that rely on manual verification processes are potentially at risk for human error. Inaccurate data entry increases the costs associated with medical billing areas and hinders interoperability as more patient data is created, collected and shared. And when incorrect data is entered when billing for services, it can result in disputes with insurance companies, medical billing errors and in extreme cases, a lawsuit and the need for omissions insurance. Performing employment verification checks by hand is also time-consuming and places an extra burden on staff, especially if there are existing staff shortages. Manual eligibility verification can hinder operational efficiency so much that the CAQH reports it adds more than 20 minutes per transaction, at a cost of nearly $10 billion per year to medical providers. Manual submissions can also result in mistakes when inputting claims, and when claim submissions aren't clean, reimbursements can take longer. 4. Unclear communication Provider and patient communication is a fundamental part of verifying coverage, ensuring receipt of payments and creating strong patient/provider relationships. If communication is unclear or rocky, it not only can undermine the trust between a patient and provider, but it can directly result in delayed claim processing, denials and make it harder to get paid. When patients and providers aren't clearly communicating about coverage, co-pays, cost estimates and deductibles, it can make for a stressful patient experience. With 3 in 10 patients expressing concerns about being able to afford a $500 bill, it's critical to inform patients about their financial obligations upfront so they can plan accordingly. How automation can eliminate eligibility verification errors According to an Experian Health survey, one in three healthcare executives say that denied claims happen about 10%-15% of the time, resulting in billions of dollars in lost revenue. Using an automated medical insurance verification system, such as Experian Health's Insurance Eligibility Verification solution, can help eliminate the vulnerabilities of manual patient eligibility verification and pay big dividends across the revenue cycle. Kate Ankumah, Product Manager at Experian Health, says, “If providers don't have a full picture of the patient's payable benefits, deductibles, co-pay thresholds out-of-pocket maximums, and other policy details, they run the risk of non-reimbursement. For that reason, these checks should be carried out before a patient's appointment or procedure, to prevent awkward billing issues and delayed payments. This gives providers peace of mind that they'll be reimbursed for the services they provide and accelerates patient registration.” Not only does automation help relieve the manual burden placed on staff, but it also improves operational efficiency, ensures cleaner claim submissions, speeds up reimbursement, reduces medical billing errors and creates a better patient experience overall. Here's how: 1. Integration with office software systems To keep things running as smoothly as possible, providers should consider automation eligibility tools that integrate seamlessly with their existing systems and interfaces. This can help fully leverage data analytics and streamline operations. Integrating automated solutions with health records can also speed up verification and registration. For example, existing Experian Health clients can access Eligibility Verification through eCare NEXT® which provides a single interface to manage several patient access functions. 2. Real-time connections with major insurance carriers Using insurance verification software can help keep patient insurance information up-to-date. For example, Experian Health's solution connects with over 900 payers instantly, allowing providers to access real-time patient eligibility and benefits data. Plus, it has an optimized search functionality that boosts the likelihood of finding a patient match. It also features an optional Medicare beneficiary identifier (MBI) lookup service that automatically finds and validates MBI numbers, necessary for validating Medicare coverage that many providers report having to look up manually. 3. The ability to calculate a patient's estimated payments Inconsistencies between estimated and actual costs are common patient complaints. By providing estimates upfront, providers can reduce this major source of patient stress. Automating pre-service eligibility and estimates provides patients with a clear view of their financial obligations so they can plan accordingly. Price transparency also empowers patients and can help them feel more in control, improve engagement and increase the likelihood that providers can collect payments faster and more efficiently. Prevent eligibility verification errors to get paid faster Insurance verification is an often underestimated, yet crucial component of the patient experience. Automating this process with advanced data analytics can help minimize denied claims and long-term financial losses while strengthening trust between patients and providers. In short, optimizing for insurance verification early on has wide-reaching benefits throughout a provider's revenue cycle. Learn more about how Experian Health can help healthcare organizations reduce eligibility verification errors and protect their bottom lines.

“With Coverage Discovery, Luminis Health can now find more billable coverage, whether primary, secondary, Medicare or Medicaid. Luminis can follow up immediately with payers when there is no initial real-time eligibility response available. Not only does this improve financial performance, but it also reduces manual work and minimizes errors before claims are filed.” Sheldon Pink, Vice President of Revenue Cycle at Luminis Health Challenge Luminis Health is a not-for-profit health system with an annual revenue of $1.2 billion and over 9000 employees. As one of the top three hospitals in Maryland (according to the U. S. News and World Report), Luminis’ vision is to break down barriers to health and deliver more high-quality care across the region. Finding and verifying insurance coverage for more self-pay patients was contributing to Luminis Health’s levels of bad debt. Staff relied on manual processes that were time-consuming and inefficient, and a vendor solution that did not integrate with Epic®. Limited productivity led to delays, denials and compromised patient experiences. To resolve these challenges, the organization’s goals were to: Create a positive patient financial experience by providing accurate and quick patient financial estimates Reduce bad debt by finding accurate primary and secondary insurance coverage Eliminate manual processes for following up real-time eligibility (RTE) responses with payers Reduce the number of self-pay patient accounts that end up in bad debt Solution With Coverage Discovery, Luminis was able to maximize reimbursement, reduce bad debt and improve the patient experience. Coverage Discovery finds additional active coverage that patients may have forgotten about. Using verified patient information, proprietary databases and confidence scoring, the tool scans for active coverage across the entire patient journey. This means no financial stone is left unturned before the patient is billed directly. By identifying coverage that would otherwise have been missed, Luminis can avoid misclassifying patients as self-pay, and prevent accounts from being incorrectly sent to bad debt or charity. Staff can focus on accounts most likely to be rebillable to insurance, rather than wasting time on avoidable manual rework. In certain instances when patients do not know they have secondary coverage, Coverage Discovery: Verifies patient demographics to ensure patient details are correct Leverages a range of proprietary databases (including Employer Group mapping) and historical patient search information to find insurance that may have been used and verified at other locations Applies a confidence scoring system to reduce the noise and eliminate “false positives,” so the client doesn’t waste time reviewing incorrect information or irrelevant coverage Outcome As a result of using Coverage Discovery, Luminis found more than $240k in active coverage on average per month in 2021. They reduced the number of self-pay patient accounts ending up in bad debt and created positive patient financial experiences by minimizing patients’ financial obligations. Reducing reliance on manual processes also led to fewer real-time eligibility responses from payers. Sheldon Pink reports that implementation was straightforward, thanks to Coverage Discovery integrating seamlessly with Epic® and support from the Experian Health team: “We’re impressed with these results and with the partnership with Experian Health. Luminis is looking forward to building on this success and continuing to collaborate with the Experian Health team.” Find out more about how Coverage Discovery helps healthcare organizations find missing and forgotten coverage, to improve financial performance and contribute to a better patient experience.

Nearly 40% of patients postponed medical care for themselves or a family member in 2022 due to cost. The percentage jumped 12 percentage points in a year, from 26% in 2021 to 38% in 2022, according to Gallup's annual Health and Healthcare poll. While this trend has clear ramifications for healthcare, it's also bound to affect revenue and collections for healthcare providers. Providers need to stay ahead of the curve when it comes to navigating staff shortages, decreased patient volume, and the range of financial problems patients are currently facing. Matt Hanas, Lead Product Manager at Experian Health, shared how providers can improve collections as patients postpone care. Q1: New studies show that many patients are putting off care due to costs. What does this mean for collections? “We're hearing about this very exact concern directly from our clients,” says Hanas, “and it's unfortunate to see patients put off medical care due to rising costs. Patients across our nation are struggling to balance where to allocate their hard-earned dollars, and they're having to make difficult decisions about whether to seek medical care or use that money on their everyday necessities. Meanwhile, healthcare providers are once again adapting to a shifting climate: “Clients are meeting this trend head-on with adaptable plans of action that allow for customizable contact strategies driven by automation and powerful data sources, using Experian solutions like Collections Optimization Manager,” says Hanas. “[Postponed care] doesn't have to be a heavily felt impact in collections if health organizations can quickly and easily adjust their collections strategies according to economic shifts, such as reduced patient volumes.” When volume is down, efficiency is key. “Experian's suite of products allows clients to utilize the tools and data we can provide to pivot on some of their outreach approaches,” Hanas says. “Segmentation results allow them to consider, for example, focusing on lower balance accounts with a consistent pattern of good payment history, or increasing collections efforts on higher balance accounts that may be harder to collect on. Having access to this data and following it is very key in preventing significant revenue interruptions during these patient volume shifts that we are seeing right now.” Q2: How can providers improve collections amid staffing shortages? “Automate as much of your workflow as possible,” Hanas advises. Automation not only reduces the need for staff intervention but also helps manage the complexity that comes with postponed care. Patients who have put off getting medical treatment may require more extensive (and expensive) treatment. If they've postponed care because of cost, it could be a sign that their finances are stretched. A complicated collections environment needs more than additional staff hours; it calls for data-driven insights and automation. “Visibility, powered by data, drives actionable workflows,” says Hanas, who points out that using solutions from Experian Health allows healthcare providers to accomplish more with fewer staff, including: Automatically pushing updates into an EHR system without manual intervention Setting up automated, prescheduled dialing and texting campaigns Prioritizing collections based on propensity to pay Adjusting scrubs and screens on AR files to remove accounts that are unlikely or unable to pay Sending text-to-pay message alerts Giving patients self-service payment options through online portals and mobile apps “I'm not saying you can completely replace the human touch throughout collections,” says Hanas. “But automation, data-driven insights, and user-friendly, self-sufficient payment collection tools can minimize the impact felt from staffing shortages by ensuring that staff collections efforts are efficient, and by offering patients that power, that freedom to use the self-service payment tools they are very eager and willing to use.” The return on investment speaks for itself. “Our collections solutions have a 9:1 return on investment ratio, based on clients' 2022 data,” says Hanas. “We think that's a pretty remarkable ROI.” Find out how University of California San Diego Health used Collections Optimization Manager and Coverage Discovery to increase collections from $6 million to $21 million. Q3: How does access to multiple sources of data improve collections success in the current environment? “Data gives our clients a compass that guides them very precisely, so they know which patients to focus on and what strategies to deploy,” says Hanas. “Experian is one of the largest data aggregators in the world, which benefits products like Collections Optimization Manager heavily—but it doesn't stop there. Experian Health doesn't rely solely on credit data; it also includes non-credit consumer data. We continually partner to grow our arsenal of data sources, so clients have a laundry list of solutions and products powered by this accumulated portfolio of data sources.” Here's how providers are using Experian's suite of collections solutions to help patients and improve collections efforts: Qualifying patients for Medicaid - “Data sources may show coverage that's been simply overlooked or forgotten by the patient,” says Hanas. “For example, Coverage Discovery has found a ton of Medicaid coverage for patients who simply didn't know they had it—or who failed to report it.” Recently, the expiration of the COVID-19 public health emergency caused millions of patients to lose their Medicaid coverage overnight.  In these cases, providing information to patients who are confused about coverage benefits both providers and patients. Hanas notes: “When we find patients are eligible for Medicaid coverage, they're really pleased to find out that their self-pay balances will be covered.” Filtering out difficult-to-collect accounts can improve collections - Screening can save providers valuable time and resources they might otherwise spend trying to collect from patients who are unable to pay. Hanas says, “Simply being able to identify that someone's address is not current or deliverable saves providers money on statement processing and postage—and saves them the trouble of attempting to send a bill that cannot be delivered.” Gaining insight into financial circumstances - “Our data gives our clients visibility into consumers' financial status changes—paying off a car loan or securing a new mortgage, for example, are things that our clients really need to know. By monitoring these financial status changes, our clients can increase or decrease their collections efforts based on what they see,” Hanas explains. Q4: How can providers support their patients who may need extra financial assistance? “Identifying patients who are eligible for charity care and other forms of assistance is probably the most rewarding use of our data, models, and algorithms,” says Hanas. “Patient Financial Clearance, which falls under the Collections Optimization suite of products, shows which patients may automatically qualify for charity. For those who do, clients can set up automation rules on the back end to automatically write off balances. This happens through a seamless integration, so it's virtually effortless. “Providers can also use the propensity to pay tool in Patient Financial Clearance to identify patients with a low likelihood of paying and offer payment plans that may help them meet their obligations. By having these conversations early in the process, healthcare organizations can keep more accounts out of collections and patients can receive medical care without having to worry about what's going to come after their visit.” The bottom line “Clients want to centralize their business operations around their patients and their care, to find the best approaches to looking after patients' health as well as their financial health,” Hanas says. “We don't want to send everyone who has a balance to collections: We want to use the different tools we have to assist them up front so they can get the medical care they need without feeling stressed and thinking about possible bills down the line. Learn more about how Collections Optimization Manager and Experian Health's full suite of collections solutions can help providers protect profits and drive revenue.

The digitization of healthcare hasn't necessarily translated to better patient access, according to recent findings. Shockingly, almost half of healthcare providers and a fifth of patients have reported that gaining access to care has actually become more challenging in the past two years. Despite significant technological investment, it appears there is still room for improvement when it comes to ensuring patients receive the care they need in a timely, efficient manner. Experian Health’s latest investigation into the state of patient access reveals that patients and providers are enthusiastic about maintaining the digital momentum, but still see room for improvement. The State of Patient Access 2023 – the Digital Front Door is the third in a series of reports that began in 2020. This survey looks at trends, challenges and priorities when it comes to patient access. The new report reveals findings from a survey carried out in December 2022 – which involved more than 1,000 patients and more than 200 healthcare providers across the U.S. As patients become increasingly tech-savvy, their expectations for a streamlined healthcare experience are evolving. It's no longer enough for healthcare providers to offer traditional services - patients now expect digital patient access services to be standard. Providers recognize the advantages of digitalization but remain sensitive to the operational challenges. This article highlights three areas of opportunity for providers to not only open their digital front door, but also secure a competitive advantage for years to come. The State of Patient Access 2023 report is based on a new survey, fielded in December 2022, that gathered responses from 202 healthcare professionals responsible for patient access and 1,001 patients who engaged in care for themselves or a dependent in 2022. It is the third survey in a series fielded by Experian Health since 2020. Opportunity 1: continue to expand digital options in patient access 56% of patients want more digital options for managing their care 69% of providers agree that mobile access is important to patients Both patients and providers want access to be streamlined and efficient. Providers recognize that patients are looking for more digital options, though some are concerned about their current technology’s ability to meet demand. This perhaps explains why nearly half intend to invest in digital technology in the next six months. Providers that leverage technology to reduce friction at patient intake will secure a competitive edge. Beyond delivering a better patient experience, providers see digitalization as a route to operational efficiency, increased capacity and better resource management. 36% of respondents are more optimistic about the state of patient access in 2023, thanks to technology offsetting ongoing staffing shortages. Opportunity 2: implement online self-scheduling to remove barriers to care 78% of patients who think patient access has worsened say the biggest challenge is seeing a doctor quickly 40% of providers have implemented self-scheduling within the past year Speed is the greatest access challenge for patients. In fact, “Seeing a practitioner quickly” has stayed at No. 1 on the patients’ “most challenging” list for the past three years, trending up every year. Patients that think access is worse blame slow scheduling processes, while those that think access is better attribute this to faster scheduling. Meanwhile, providers say that getting patients to engage with digital services so they can see a doctor quickly is their top priority. This points to a huge opportunity for providers to implement scheduling technology that closes this gap, since 56% of patients who think access is worse would switch providers because of this issue. Online self-scheduling gives patients the freedom to book and cancel appointments at their convenience, eliminating the hassle of picking up the phone or waiting on hold. Providers benefit from reduced administration errors, no-shows, and denied claims. With smart integration into scheduling protocols, every timeslot can be filled so patients can see their doctor sooner. Opportunity 3: simplify the financial experience for patients 26% of patients say paying for healthcare is worse than previous years 63% of providers believe patients frequently postpone care due to the cost of care A third opportunity encompasses the patient’s financial journey. Giving patients more power over their payment options is becoming increasingly vital. This is particularly true for younger generations who prioritize digital payment solutions. As these demographics continue to seek more convenient, flexible, and varied payment methods, it will be critical for healthcare providers to address these concerns in order to foster long-term patient satisfaction. Simplifying the experience with accurate pre-care estimates, early payment plans, digital payment options and patient portals means patients will find it easier to pay their bills. Price estimates, in particular, have become increasingly important to nearly 90% of patients; however, the survey reveals that less than a third of patients are actually receiving it before their appointment. This highlights the urgent need for healthcare providers to prioritize transparency and provide clear pricing well in advance. By adopting frictionless payments, healthcare providers can reap many benefits. One major perk is that patients are less likely to put off medical care when the payment process is simple and smooth. Not only that, but providers can expect to see faster collections and a boost in their bottom line. Plus, leveraging digital technology can streamline mundane back-office tasks, leaving staff with more time to focus on other important work. Embrace digital patient access to secure long-term patient loyalty Navigating the pandemic, staffing shortages, and economic volatility has been a bumpy ride for healthcare providers. But amidst the turbulence, one silver lining has emerged: the power of digital technology to enhance patient access. Experian Health’s three surveys show that providers have worked hard since 2020 to reduce friction in patient access, and are seeing the pay-off in higher patient satisfaction. But there’s still work to do. Providers that leverage technology to deliver convenience, transparency and potentially reduced costs to patients will be rewarded with loyalty, and better financial performance in the long run. Download The State of Patient Access 2023 – the Digital Front Door to see the full results.

Healthcare claims management is getting a much-needed infusion of technology. Artificial intelligence (AI) is the key player, utilizing vast amounts of data related to human behavior and health to forecast patterns in disease outcomes with greater precision than ever before. The same analytical power can be applied to claims data to predict and prevent denials. Using artificial intelligence for claims management is now more crucial than ever. By rooting out errors, evaluating trends and predicting payer behavior, AI helps reduce the likelihood of denied claims and maximize revenue opportunities. Staff can spend less time “treating” the effects of denied claims. But even when denials occur, AI still plays a role, quickly triaging high-value denials so staff uses their time efficiently. This two-pronged, proactive and reactive approach is captured in Experian Health's AI Advantage solution™. Using AI-powered analytics and automation, this technology helps providers predict, prevent and process denials to improve claims management and increase revenue. It's time to update claims management systems In Experian Health's State of Claims survey, nearly 3 out of 4 healthcare executives said reducing denials was their top priority. Denials are increasing in number, taking longer to process and taking a bigger bite out of provider profits. Traditional claims management strategies are no longer fit for purpose. The volume and complexity are too much for manual processes to handle, resulting in errors, time-consuming rework and lost revenue. Many providers are using automated claims management platforms to code and edit claims before they are submitted. Automation is ideal for these highly repetitive processes. Faster and more efficient claims processing increases clean claim rates and speeds up reimbursement. Experian Health's automated claims management solutions are designed with these outcomes in mind, with ClaimSource® and Contract Manager named among the best-performing claims management products in 2023, according to a KLAS report. Artificial intelligence builds on the benefits of automation, providing insights and recommendations to drive better decision-making. While automation frees staff from time-consuming, process-driven tasks, artificial intelligence allows them to perform remaining tasks at a higher level. For example, when it comes to processing denials, staff will often “guesstimate” each claim's potential for payment. They'll usually focus on reworking the highest-value denials first. AI removes the guesswork so staff can prioritize denials based on monetary value and likelihood of reimbursement, so time isn't wasted chasing higher payments that may never materialize. Using artificial intelligence for claims management can predict and prevent denials A successful denial reduction strategy starts upstream, to proactively prevent denials before they occur. AI Advantage ­– Predictive Denials uses AI to review claims before they're submitted and flag any that are likely to be denied, based on historical payment data and payer adjudication rules. The tool detects changes to the way payers handle denials, even if those aren't explicitly documented. If a claim exceeds the (customizable) threshold for probability of denial, Predictive Denials alerts the appropriate biller, who can then intervene and make corrections prior to claim submission. The benefits of this “early detection” approach include: Reducing the number of denials to be processed (and staff time spent processing them) Reducing AR days by flagging high-risk claims Improving patient satisfaction by avoiding lengthy appeals processes. After using AI Advantage – Predictive Denials for six months, Schneck Medical Center reduced average monthly denials by 4.6%. Reworking claims flagged with a predictive alert took 3–5 minutes, which was significantly quicker than before. By frontloading staff time to get claims right the first time, less effort was spent on denials. Implementation was straightforward, with no disruption to the existing claims workflow. Triaging denials for faster, more effective rework The second piece of the AI Advantage solution addresses denials that haven't been prevented. AI Advantage - Denial Triage uses advanced algorithms to identify and segment denials so staff can focus on the most profitable resubmissions. Denials are automatically triaged into five customizable categories based on likelihood of approval. Staff can rework the claims in their work queue without wondering if they're putting their effort in the right place. By automating decisions about which claims to prioritize for rework in real time, Denials Triage eliminates time spent on low-value denials and increases revenue by prioritizing high-value claims. As with Predictive Denials, this reduces the administrative burden on staff, expedites AR days, and increases patient satisfaction by reducing time to decision. Extending the automation advantage To maximize reimbursements, providers need to look at opportunities to leverage automation and artificial intelligence across the entire claims ecosystem. AI Advantage integrates with existing systems and workflows to leverage the impact of tools such as ClaimSource®. ClaimSource manages the whole claims cycle from a single online application. AI Advantage uses real-time insights generated by ClaimSource to detect patterns and predict future payer behavior. Other ways to use automation to improve claims management include: Automated claim scrubbing - Claim Scrubber uses machine learning to assess which claims have been denied in the past and why. Claims can be tagged for extra checks before being prepared for processing, to ensure likely errors have been avoided. This helps eliminate undercharges, reduce errors and minimize rework. Enhanced claim status monitoring – This helps providers keep track of existing claims. Automated status requests based on each payer's adjudication timeframe reduce manual follow-up work and allow staff to respond promptly to issues. Gathering insights into potential problems before the electronic remittance advice and explanation of benefits are processed creates time to make corrections. Using a denials workflow manager - This system automates and optimizes the denial management portion of the claims cycle, so staff can improve productivity and speed up reimbursement. With a single vendor, these tools and systems are designed to work cohesively, so there are no issues with interoperability. Data is reliable, accessible and integrated, so automation can pull from the most up-to-date and complete sources. This data can feed into proprietary machine-learning algorithms to predict and shape future performance. Experian Health's suite of automated claims management software solutions also comes with support from experienced claims-specific experts, who can help staff optimize their set-up and workflows. With the rise of AI, the healthcare industry is turning towards a more proactive approach to claim denials. Leveraging artificial intelligence for claims management can improve the overall efficiency and accuracy of healthcare claims processing, leading to fewer denials and a more seamless patient experience. Instead of waiting for denials to occur before taking remedial action, providers can use AI and automation to proactively detect errors and diagnose weaknesses in the claims process for a healthier revenue cycle. Discover how AI Advantage can help healthcare organizations predict and prevent claim denials.

U.S. hospitals have been stuck with more than $745 billion in uncompensated care costs for the past 2 decades, and the number continues to grow.  Other factors like patients relocating, changing employers, and coverage renewals make recovering debt even harder. The recent end in COVID-19 funding has also made it more important than ever for healthcare providers to find missing insurance coverage. Finding insurance coverage can be complicated and time-consuming, especially in an already complex reimbursement landscape. However, it doesn't have to be. That's where Coverage Discovery comes in. Coverage Discovery is the only comprehensive coverage identification solution across the full revenue cycle continuum. It covers the entire patient process and uses multiple proprietary data repositories, advanced search heuristics, and machine learning matching algorithms to search government and commercial payers to find previously unknown insurance coverage. This includes identifying accounts that may be submitted for immediate payment as primary, secondary or tertiary coverages. This automated coverage identification solution can search for unidentified coverage pre-service, at the point of care, and post-service. It also scans for insurance coverage continuously - to maximize reimbursements and minimize accounts sent to collections and to charity.  In 2022, Coverage Discovery tracked down previously unknown billable coverage in more than 28.1% of self-pay accounts and found more than $64.6 billion in corresponding charges. Learn more about this solution: It's time to reduce bad debt and improve cash flow. Identifying hidden insurance coverage is the first step to managing insurance denials and your organization’s healthcare financial performance. A solution like Coverage Discovery can help healthcare organizations save time, money and alleviate staffing shortages. To learn more about how Coverage Discovery can benefit your healthcare organization, contact us.

Proactive price transparency could be a competitive advantage for healthcare providers, as a Kaiser Family Foundation survey suggests a majority of Americans believe Congress should prioritize the issue. The survey revealed that 60% of respondents think legislative action to make healthcare prices more transparent should be a “top priority” for the next Congress, while a further 35% said such laws were “important, but not a top priority.” Concerns about the cost of living are top of mind for many households, with 91% of respondents specifically noting their worries about rising healthcare prices. Providers can help meet the demand for more transparent pricing by implementing solutions to make it easier for patients to understand and plan for upcoming bills. Those that proactively meet and exceed patient demand for clearer pricing information will garner more patient trust and loyalty, and in turn, secure an important competitive advantage in a challenging economic context. Why are patients calling for greater price transparency? For many patients, the process of paying for healthcare is like trying to find their way through a maze, with numerous twists and turns and no clear path forward. Unlike most other purchasing decisions, patients lack upfront information about the options in front of them. Many do not fully understand the cost of care, and as a result, may not be aware of or prepared for the forthcoming financial burden. This lack of transparency causes uncertainty and unease, leading to postponed care or missed payments. With transparent pricing, patients can make more informed decisions and choose the most cost-effective options. Those with high out-of-pocket expenses can shop around for services that best fit their budget and estimate the cost of care in advance. Transparent pricing is especially important for patients with chronic conditions or those who require ongoing care. Are providers meeting the demand for price transparency? Many providers have embraced the push for transparent pricing, by introducing upfront patient estimates and tools to help patients understand and manage their bills. Transparency may be a requirement under the Hospital Price Transparency Final Rule, but providers are also incentivized by the promise of faster payments and fewer time-consuming billing queries. However, implementation of price transparency measures has been patchy: as of August 10, 202, only 16% of hospitals were compliant with the rule. In a podcast interview for Becker’s Hospital Review with Riley Matthews, Lead Product Manager at Experian Health, Jamie Cleverley, President of Cleverley + Associates, suggests two main obstacles: confusion around what information needs to be disclosed (more on this below) concerns that sharing pricing information could negatively affect revenue. The second concern is valid, but evidence suggests that disclosing prices to patients can save money, by reducing unnecessary hospitalizations, readmissions and emergency visits. Missed payments are less likely if patients feel in control of their financial situation. In fact, research by Experian Health and PYMNTS suggests that upfront cost estimates improve patient satisfaction by 88%, which encourages prompter payments. Delivering a better patient experience with accessible pricing information To help healthcare organizations meet patient demands for clearer pricing and ensure compliance with the federal rule, Experian Health and Cleverley + Associates have teamed up to provide a standardized solution. Listen in as Jamie Cleverley, President of Cleverley + Associates, and Riley Matthews, Lead Product Manager at Experian Health, discuss how a new partnership is helping providers comply with the Price Transparency Rule: Each organization brings its specific expertise to help healthcare providers provide clear and compliant pricing information: Experian Health’s Self-Service Patient Estimates tool enables compliance with the requirement to display payer-specific rates as a consumer-friendly list of 300 shoppable items. This tool gives patients upfront, accurate estimates that are easy to understand so that they can make informed choices about their care. Cleverley + Associates helps providers make pricing information available as a machine-readable file, quickly and at scale, so providers can fulfill the requirement to display such files on their website. The solution is neatly packaged to save providers from engaging in discussions with multiple vendors or scrambling to find internal solutions for each individual requirement. Cleverley says that working with the two organizations together can save providers time and stress: “We have the information and the technical capacity to offer a format we think is useful, which complies with all the rules. There’s anxiety around this – providers worry about whether CMS will view [their solutions] as compliant. But with us, they’re working with trusted partners that have had those conversations with CMS, that have released these files already and that have been through the audit process.” For Matthews, this adds up to a user-friendly experience that’s not only compliant but gives patients what they need: “We needed to provide a patient-facing estimate-creating solution that shows those top 300 shoppable services for a hospital or a doctor’s office. We were able to do that through our existing product, Self-Service Patient Estimates. We have this portal that we can integrate with our clients’ websites, which guides patients through the entire process. What we did not have – and where Cleverley came in – were those complex machine-readable files… So, we were able to come in from both sides with price transparency and say, ‘ok, now we solve both, and we’re here to provide a holistic solution.’” From compliance to competitive advantage Penalties for non-compliance with the Price Transparency Rule may have been limited to date, but this may change as the rule reaches its second anniversary. Furthermore, some states are starting to bring in their own legislative measures to protect patients from opaque billing practices. And with patient expectations clearly stated, the pressure on providers to deliver transparency is mounting. But as noted, this is about more than compliance. Patients are looking for a clear and compassionate financial experience and will reward providers that deliver this. Providers should consider how to keep patients informed and empowered at every stage of the financial journey. Experian Health offers a suite of payment tools designed to achieve this, which bring together accurate estimates, tailored payment plan recommendations and convenient payment options. Find out more about Experian Health’s Price Transparency Solutions or watch the video to hear more about Experian Health’s price transparency partnership with Cleverley + Associates.

With inflation still high, the economic outlook remains uncertain for healthcare consumers. Many households feel squeezed by rising housing, food and fuel bills, while their incomes remain broadly static. Inflation’s impact on healthcare can be seen in delayed treatments, as a 2022 Gallup poll found that 38% of patients postponed medical care because of concerns about costs – the highest amount since the poll began in 2001. The situation is exacerbated by the fact that Medicaid continuous enrollment came to an end on March 31, 2023. To complicate things further, reimbursement rates and employer health plans tend to be negotiated in advance, which means inflation can take longer to filter through the healthcare economy. Both McKinsey and Deloitte predict that hospital profit margins will reduce in the coming year or so. Resulting price increases will be reflected in employer coverage plans, and ultimately pass to workers in the form of higher deductibles and out-of-pocket costs. In short, inflation’s impact on healthcare may continue to create ripples in the healthcare industry. For healthcare providers, reimbursement may become more challenging as patients find it harder to pay their portion of the cost. What can providers do to mitigate inflation's impact on healthcare? Providers are already working to maximize operational efficiency with automation and digital tools that reduce workforce pressures, streamline back-office processes, and leverage data to drive improvements. Reducing costs is just one side of the coin. The other is to maximize opportunities for reimbursement by supporting patients throughout their financial journey and making it as easy as possible for them to pay. Here are 4 ways that healthcare providers can mitigate inflation’s impact on healthcare while reducing friction for patients and maintaining cash flow: 1. Provide transparent pricing and upfront patient estimates Because inflation has forced patients to prioritize their spending, many are opting to postpone healthcare. But delaying treatment or stretching out medicines to save money could lead to poorer health outcomes, and potentially more expensive treatment being needed later. By proactively offering patients accurate pricing estimates before they come in for care, providers can help patients get a fuller picture of what their final bills are likely to be. Estimates can be sent directly to the patient’s mobile device, along with user-friendly links to payment plans and payment methods. This makes it much easier for patients to plan, so they’re less likely to default on payments or delay care. 2. Help patients find unknown insurance coverage With the end of continuous Medicaid enrollment, millions of patients could have gaps in coverage. While this is largely an issue for states to manage, providers can take steps to help patients find additional coverage, and support those at greatest risk to find financial assistance and plan for upcoming bills. Coverage Discovery can be used at any point in the revenue cycle to search for missing or forgotten billable coverage. It uses advanced search and proprietary data sources to check for both government and commercial insurance coverage. When coverage is found, patients get the reassurance of knowing that their bills will be covered, while providers can avoid writing off these accounts to bad debt. And because Coverage Discovery uses a contingency fee pricing model, providers only pay for the tool when they are reimbursed. 3. Offer simple and convenient methods to plan and manage bills Prescription medications, inpatient visits and other services are expected to increase in price over the coming year. Americans may be more concerned about how they’ll shoulder the costs – especially the 49% who say they’d be unable to pay an unexpected bill of $1000 or more. Providers can make the process easier for patients with data-driven digital tools. Patient Financial Clearance identifies patients that are likely to be able to pay upfront and those who may need a payment plan or financial assistance. This information allows providers to engage in compassionate financial counseling to make sure patients are guided to the most appropriate pathway. Another option is to leverage self-service tools to give patients more control over how and when they pay. Patient Financial Advisor offers pre-service estimates and payment options that patients can access anywhere, anytime. They can take stock of their financial situation, plan for bills, and then make payments at the click of a button. If it’s easier to pay, patients will be less likely to delay. 4. Make it easier for patients to schedule care While many patients may consider delaying care because of cost, many say they’ve postponed treatment for other reasons. Concerns about COVID-19, work commitments, and difficulty booking appointments can also lead to delayed care. For those that are foregoing care for reasons other than cost, providers should look at improving the patient access experience with more self-service options. Online self-scheduling allows patients to book, reschedule and cancel appointments at their own convenience. Digital patient registration similarly reduces friction, by enabling patients to fill out forms from their mobile devices. Patients will be less likely to forego care when access is as easy as ordering groceries online. Proactively reducing inflation's impact on healthcare Inflation’s impact on healthcare continues to be felt – and could get worse as the year goes on. Rising medical bills may cause patients to keep deferring care. Providers can proactively reduce the effects by incorporating digital solutions and patient engagement strategies that make it easier for patients to afford and receive care. Find out more about how Experian Health can help healthcare organizations bolster their revenue cycles and mitigate inflation’s impact on healthcare.