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How to reduce claim denials with AI

November 21, 2023 by Experian Health

The complexities of healthcare claims management are a widespread, costly issue. While the American Medical Association (AMA) blames prior-authorizations as the main cause, it’s clear that hospitals struggle to collect on predicted revenues often for months after they provide the service. It’s not a sustainable situation as the costs of care delivery increase, staffing shortages drive up labor overhead, and inflationary pressures stretch healthcare providers to their breaking point. There is no question the claims denial process is ripe for innovation – and that’s where artificial intelligence (AI) comes in. A 2022 Experian Health survey shows over one-half of healthcare providers increasingly turn to AI-driven healthcare claims management software to reduce claim denials.

Tom Bonner, Principal Product Manager at Experian Health, says, “Adding AI in claims processing cuts denials significantly. AI automation quickly flags errors, allowing claims editing before payer submission. It’s not science fiction – AI is the tool hospitals need for better healthcare claims denial prevention and management.”

Common reasons for medical claim denials

Revenue cycle leaders place healthcare claims management as their number one issue in 2023. Experian Health’s survey showed the three most common reasons for medical claim denials were:

  1. Needs more data and analytics to identify submission issues.
  2. Manual claims processing and a lack of automation.
  3. Insufficient training for staff.

The sheer volume of changes to CPT codes is another issue affecting HCM or healthcare claims management. Experian Health identified more than 100,000 payer policy changes from March 2020 to March 2022. These shifts necessitate a never-ending cyclic need to train new staff, increase the risk of claim rejections, and slow down manual workflows in healthcare claims denials management. How can healthcare providers improve claims processing and overcome these challenges?

Real-life ROI with AI in claims processing

AI in claims processing solves these and other common revenue cycle problems. This technology is the innovation healthcare providers need to reduce denials and increase cash flow. AI can help at every point in the revenue cycle continuum, from improving the accuracy of payer data upfront to ensuring a clean claim and even targeting denials that yield the highest return. What real-life lessons does AI in claims management teach healthcare providers?

Experian Health’s new AI-powered solution includesAI Advantage™ – Predictive Denials and AI Advantage™ – Denial Triage, which is geared towards helping healthcare organizations reduce claim denials.

Within six months of using AI Advantage, Schneck Medical Center reduced denials by an average of 4.6% each month. Claim corrections that formerly took up to 15 minutes to correct cut to just under five minutes.

Even smaller ambulatory clinics like Summit Medical Group Oregon benefit from automating healthcare claims management. After implementing Experian Health’s claims management software, the provider saw an immediate reduction in claims denials. Today, they boast a 92 percent clean primary claims rate.

These results are typical across healthcare organizations that implement AI in claims processing. But what does the software do to clean up the complexities of claims management processing?

How to avoid claim denials with AI

In 2022, Experian Health surveyed 200 revenue cycle leaders around the country and identified technology shortfalls as a significant contributor to claims denials:

  • 62% reported they lacked the data analytics to identify submission issues.
  • 61% said manual processes and a lack of automation were significant problems.
  • 33% suggested their healthcare claims management software was outdated or inadequate.

Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software. The benefits of these tools lie in their ability to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can also assist in identifying inaccurate claims, improving claims processing accuracy and revenue cycle management. By using automation and AI together, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency.

Tom Bonner says, “AI in claims processing maximizes the benefits of automation for better claims processing, better customer experiences, and a better bottom line for healthcare providers.” How does healthcare claims denial management software work to improve the revenue cycle?

AI identifies and prioritizes high-value claims after denial

AI in claims processing goes beyond automating process-driven manual tasks. It also removes the guesswork from healthcare claims management. For example, staff is often left guessing which denied claims are the low-hanging fruit that they should process first. Staff must decide which denied claims have a higher likelihood of reimbursement and a higher dollar value to maximize their efficiency. Why would healthcare providers leave these high-value/high-return claims to a manual “best guess” estimation process? Yet that is standard operating procedure in most hospitals.

AI in claims processing identifies and prioritizes high-value claims automatically. Experian Health’s AI Advantage – Denial Triage goes to work when a claim is denied by identifying and intelligently segmenting denials based on potential value so that staff focuses on resubmissions with the most significant bottom line impact. This intelligent segmentation removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials.

But the front-end work AI software completes during healthcare claims management may be even more valuable. AI can prevent claims denials from occurring at all.

AI proactively stops claim denials from occurring

AI Advantage – Predictive Denials uses AI to identify undocumented payer adjudication rules that may result in new denials. It identifies claims with a high likelihood of denial based on an organization’s historical payment data and allows them to intervene before claim submission.

Experian Health also has other automated solutions that help facilitate claims management. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they’re submitted, helping to optimize the revenue cycle. The software also generates accurate adjudication reports within 24 to 72 hours to speed reimbursement.

ClaimSource ranked #1 in Best in KLAS 2023, precisely for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster.

AI optimizes the claims process

Another Experian Health solution, Enhanced Claim Status improves cash flow by responding early and accurately to denied transactions. This solution uses RPA to give healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include:

  • Provides information on exactly why the claim denied.
  • Speeds up the denials process.
  • Automates manual claims follow-ups.
  • Integrates with HIS/PMS or ClaimSource
  • Automation frees up staff to focus on more complex claims.

Denials Workflow Manager integrates with the Enhanced Claim Status module to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow.

How to reduce claim denials with AI and Experian Health

There’s no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex on its own, but human error plays a large part in missed opportunities and lost revenue. With AI in healthcare claims management, the revenue cycle streamlines and transforms. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI healthcare claims management software offers provider organizations a way to achieve these goals.

Contact Experian Health today to reduce claim denials and improve your claims management process with AI Advantage.

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