Prevent claim denials with AI and automation

Published: February 15, 2023 by Experian Health


Experian Health is the top-performing claims management vendor, according to the 2023 Best in KLAS: Software and Professional Services report. Experian Health’s ClaimSource® solution, an automated, scalable claims management system designed to prevent claim denials, ranked number one in the Claims Management and Clearinghouse category.

Tom Cox, President of Experian Health, said, “We’re honored to receive this award. Our goal is to simplify the administrative aspects of care by addressing healthcare’s biggest business challenges using the power of Experian’s data, analytics and technology. By helping providers automate processes and reduce claim denials, we have a major impact on their operations and financial solvency so they can be in a better position to serve patients.”

Automated tools are a perfect fit for managing the repetitive and rule-based processes involved in processing claims and denials. Experian Health’s State of Claims survey found that just over half of providers are already using advanced automation to streamline claims management, prevent claim denials and ease pressure on staff. While the power of automation is well-established, the untapped potential of artificial intelligence (AI) is attracting more attention. AI can provide faster and richer predictions by analyzing and interpreting complex data to optimize reimbursements and curb the cost of denials.

By leveraging AI and automation, healthcare organizations can improve their claims management processes and prevent claim denials. Here are the 5 benefits of incorporating these digital tools:

1. Reduce time-consuming rework by preventing claim denials

AI and automation put providers on the front foot when it comes to reducing the frustrating number of preventable denials. Rather than waiting to discover that a claim contained a misspelled patient name or incorrect code, providers can run automated front-end checks to catch and fix errors before claims are submitted. This can be achieved through a data-driven denial management workflow, using tools such as ClaimSource and Claim Scrubber to automatically review claims line by line.

AI programs address the problem of preventable denials by “learning” from historical claims data. This can be used to identify recurring weaknesses in the claims workflow and generate predictions about the risk of future denials.

Experian Health’s new and revolutionary AI Advantage™ solution uses AI-powered analytics to help providers predict, prevent and process denials. This solution operates at two distinct moments in the claims process: before claim submission and after claim denial. One component of the solution, AI Advantage™ – Predictive Denials takes a proactive approach and works to edit claims that are at high-risk of denial prior to payer submission. The second component, AI Advantage™ – Denial Triage, steps in after claims have been denied, and identifies denials that have the highest potential for reimbursement.

Jason Considine, Experian Health’s Chief Commercial Officer, says, “AI provides the power of automation but takes it to a completely new level by adding the predictive capabilities, ongoing learning, and insights necessary to proactively prevent claims from being denied before they are submitted, speed up and prioritize rework by humans, and leverage advanced analytics to uncover actionable insights from a health system’s own data to optimize claims management across the revenue cycle.”

2. Stay in the loop on changing payer rules

Providers can only catch preventable errors if they stay sharp on payer rules. Keeping track of every individual change on hundreds of payer websites is a hugely onerous task for staff. Experian Health recorded more than 100,000 payer policy changes for coding and reimbursement over just two years during the COVID-19 pandemic. It’s frustratingly inefficient when the same notifications must be checked by multiple staff across the same health system. Automated Payer Alerts can do this work for them, by monitoring changes posted on more than 60,000 payer web pages and issuing a daily email digest to staff.

This functionality also feeds into predictive data models. To generate accurate insights about the probability of reimbursement, data models must be able to quickly integrate changing variables. If data models are built on outdated payer rules, then the predicted likelihood of reimbursement will be inaccurate. AI modeling can provide real-time, ongoing analysis and reinterpretation of data to calculate new scores and reprioritize accounts.

3. Integrate eligibility checks and prior authorizations to maximize reimbursement

Four in ten providers say they have difficulty keeping track of pre-authorizations, with nearly five in ten citing these as their top three reasons for denials. Automated solutions can flag when pre-authorization is needed, track down the necessary documentation and provide real-time reports on authorization status. Since many eligibility issues creep in during patient access, electronic prior authorizations prompt checks at every touchpoint in the patient journey, and pulls patient data to verify that proposed care meets medical necessity rules.

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:

For example, Experian Health’s online prior authorizations workflow automates inquiries and checks authorization requirements in real time. With multiple connection types to payers, this solution facilitates the prior authorization submission process.  It also uses AI to automatically bring users to the appropriate payer and connection type. Once submitted, Experian Health automates the back-end of the submission process 100%.  This help users find and access the appropriate payer portal, to increase efficiency and ensure quick and accurate submissions.

4. Prioritize recoverable claims

Denials teams often focus rework efforts on higher value claims, but if the likelihood of a successful appeal is small, the ROI will be disappointing. Jason Considine, Experian Health’s Chief Commercial Officer, says that AI can offer a considerable advantage here through data modeling for resubmissions and appeals: “By scouring the provider’s own systems of record, an AI platform can analyze the history of the claim in question, as well as similar claims, to uncover such insights as past appeal success and percentage of reimbursement recovered.”

A higher success rate for multiple smaller claims will have a much greater impact on the provider’s bottom line than higher-value claims that never get approved.

Experian Health’s AI Advantage™ – Denial Triage helps staff prioritize the most profitable resubmissions. This new solution automatically categorizes denials based on their likelihood of being approved, so staff doesn’t lose time reworking low-value claims. To maximize reimbursement, the tool can be used alongside its proactive counterpart, AI Advantage™ – Predictive Denials. Using historical payment data and a sophisticated assessment of payer behavior, Predictive Denials flags claims that are at risk of denial, so staff can intervene before they’re submitted.

5. Alleviate staffing pressures by automating repetitive tasks

Embracing automated claims management tools can free up staff time for other priorities and improve productivity across the revenue cycle. The Council for Affordable Quality Healthcare (CAQH) reports that automation could save 22 minutes per claim status inquiry. That adds up to a significant amount of time (and revenue) each month.

While AI and automation offer game-changing efficiency savings, some staff may worry that the rise of AI could lead to job losses and make certain roles obsolete. Regarding claims management, Considine suggests that AI is better thought of as enhancing rather than replacing human teams, by “handling repetitive tasks at scale and performing complex analysis, while employees focus on reworking claims most likely to realize reimbursement.” With ongoing labor shortages, anything that eases the burden on maxed-out healthcare teams should be considered.

Using AI and automated solutions to prevent claim denials

While AI is still relatively new, the potential to reduce the risk of denials through more efficient, accurate and intelligent workflows is clear. There are many AI-powered and automated solutions to help providers submit clean claims the first time. Healthcare providers should focus on leveraging these claims management tools to optimize the denials workflow and maximize reimbursements.

Get in touch with Experian Health to discuss how AI Advantage™ and other automated claims management solutions can help prevent claim denials.

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