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What do patients and providers really think about patient access services in 2024? Drawing insights from more than 1000 patients and 200 healthcare executives, Experian Health's fourth State of Patient Access survey pulls back the curtain. Previous surveys revealed a persistent gap between patient and provider perspectives on patient access, but could the gap finally be closing? The State of Patient Access 2024 report suggests that while discrepancies remain, the two groups appear closer than ever. This article provides a summary of the State of Patient Access 2024 report, and gives a run-down of patient and provider perspectives on patient access, what they see as top challenges, where opinions diverge and the steps providers can take to continue building a positive patient access experience in the year ahead. How do patients feel about patient access? 1. More patients think access has improved compared to last year 28% of patients believe patient access has improved over the last year, which is up from just 17% in 2023. As in previous years, patients' perception of whether access has improved hinges on how quickly they can see their doctor. Anything providers can do to accelerate scheduling and registration will be a winner. 2. Patients welcome the efficiency and accuracy of digital tools Patients have noticed improvements in scheduling and registration processes. They welcome the ability to book appointments anytime and avoid unnecessary paperwork using digital technology. That said, financial considerations trump convenience: the ability to look up insurance coverage and obtain accurate price estimates before care have risen to the top of the list of what patients consider the most important aspects to improve. 3. Cost of care remains a concern Unfortunately, patient sentiment around healthcare payments has remained relatively flat since 2022. Slightly more patients are receiving upfront cost estimates compared to previous years, but accuracy appears to have dropped, with 74% of patients reporting accurate estimates compared to 78% in 2023. Patients must have faith in their estimates if they are to plan for upcoming bills with confidence, and providers should be able to provide transparent and accurate payment estimates. What do providers think about patient access? 1. Providers are again more optimistic about improvements than patients Like patients, providers are generally positive about the state of patient access, though they may be a little too optimistic about the effect of improvement efforts. Around twice as many providers think access is better than the previous year compared to patients (55% compared to 28%). For providers, perceptions of improvements in patient access are closely tied to the impact of staffing levels. 2. Self-scheduling is back in favor Providers are aligned with patients on the need for digital scheduling and registration options. Interestingly, after the urgency to implement contactless scheduling during the pandemic began to wane in 2022, the latest survey suggests that self-scheduling is back in fashion, with 63% offering self-scheduling compared to 40% in 2022. 3. “Dirty data” remains a stubborn challenge Data collection at patient intake is a persistent headache for providers. Almost half (49%) say that inaccurate patient information contributes to claim denials. Improving the speed and accuracy of resolving patient information prior to claims submission were frequently listed in providers' top three challenges. See how healthcare organizations are using AI AdvantageTM to improve data accuracy and reduce claim denials. Digital technology bridges the gap between patient and provider perspectives on patient access When asked for their top three priorities for improvement, both groups ranked accurate price estimates and efficient insurance verification among their top two. While they diverge on the third – access to online health management tools for patients, and automated pre-authorizations for providers – it's interesting to note that these both reflect a desire to use digital solutions for greater efficiency and convenience. The survey highlights several opportunities to use digital technology to address upcoming challenges and continue to close the gap. Key challenges in patient access in the year ahead 1. Improving accuracy of upfront price estimates The survey showed 79% of providers plan to invest in patient access improvements soon. Given shared concerns about patients' ability to cover the cost of care, and worrying hints that some may postpone care due to cost concerns, prioritizing and providing accurate patient estimates would be a smart choice. While patients and providers are in closer agreement that estimates are accurate most or all of the time (74% and 85% respectively), there's clearly room for improvement. 2. Accelerating insurance verification and claims submission processes Several of the providers' top challenges speak to how difficult it can be to collate accurate information prior to claims submission. The need for better insurance reviews, more efficient management of prior authorizations, and more accurate patient information all contribute to the overarching goal of getting properly reimbursed. Almost a fifth say that managing multiple tools to determine eligibility, coordination of benefits (COB), and other pre-service checks is a top challenge. Could a single solution be the answer? Experian Health's new Patient Access Curator solution checks eligibility, COB, Medicare and commercial coverage, demographics and financial status in less than 30 seconds. Staff can check off several of these tedious tasks with just a single click. 3. Bolstering workforce capacity with technology A final challenge in the year ahead is the ongoing impact of staffing shortages. For the of providers who feel that staffing levels are disrupting delivery of scheduling and registration services, technology may offer a way through. Automation and artificial intelligence not only reduce the burden on staff by eliminating time-consuming manual tasks, but also allow staff to work smarter and faster on remaining tasks by improving data accuracy and insights. Most importantly, digital technology can improve scheduling, registration and payment processes for patients – and bring the patient experience in line with what both groups aspire to see. Download the full report: State of Patient Access 2024, or contact Experian Health to learn how technology can help streamline patient access.

“Is this claim valid? How much is our financial responsibility?” These are the two big questions payers want to answer when adjudicating healthcare claims. Huge amounts of patient information, clinical data, diagnostic and billing codes, and policy specifications must be analyzed and cross-checked to verify that the right amount is paid to the right party. It's a complex process. Even the smallest error can result in a claim being rejected or denied, dragging out payment timelines and eating up provider profits. That's why healthcare providers should reevaluate their claims adjudication process. 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 2024 Best in KLAS: Software and Professional Services report. Learn more The claim adjudication process is a pivotal step in the revenue cycle and determines a provider's reimbursement for services rendered. It's a complex process with many moving parts, which means errors or delays can occur at many points along the way. A smooth, streamlined system can reduce the amount of time and money spent on claims adjudication for both the payer and the provider. Here are six steps to improving claim adjudication processes for a better bottom line. What is claims adjudication? Claims adjudication is the process by which insurance companies thoroughly review healthcare claims before reimbursement or payout. During this process, they decide whether to pay the claim in full, pay a partial amount, or deny it altogether. If more information is needed, the claim will be rejected and marked as “pending.” Insurance companies employ this systematic procedure to determine the validity, accuracy, and eligibility of claims against the terms and conditions of their policy. During claims adjudication in healthcare, insurance payers assess the documentation provided by the service provider, examining factors such as the nature of the services, coverage details, and any applicable deductibles. The process can take weeks to resolve itself. This evaluative process ties up billions of dollars in an endless cycle of claims denials and resubmissions. Following this evaluation, the provider will reject or settle the claim. Additionally, claims adjudication may lead to partial settlements or modifications based on the assessment of the claim. By all accounts claims denials are exceedingly common; a recent Experian Health survey showed that these numbers have increased by up to 15% annually. Healthcare providers can implement several steps to mitigate the risk of denials, enhance the efficiency of claims adjudication and get paid faster. Steps to improving the claims adjudication process The healthcare reimbursement process is bogged down with manual tasks that create errors. Experian Health's State of Claims 2022 report revealed that the most common claims errors include: Missing or incomplete prior authorizations Failure to verify provider eligibility Mistakes in medical coding Yet providers have new technologies at their fingertips to improve how and when they get paid. McKinsey reports on data showing that applying the latest artificial intelligence (AI) and automation digital tools to the revenue cycle could save healthcare providers up to $360 billion annually. That makes these tools a kind of adjudication insurance to protect providers against costly claims denials. Here are six ways to apply technology to improve the claims adjudication process. Step 1: Invest in automation Some of the benefits of automating healthcare claims management include: Streamlined operations with fewer human errors. Less staff time tied up in claims adjudication. Better data with real-time insights into patient and payer trends. Faster claims processing—and faster payment. Better patient experiences. Happier staff. Applying AI and automation to claims management can eliminate errors by allowing the technology to validate and cleanse data at the point of entry. Tools like Experian Health's Claim Scrubber can thoroughly review each line of claim data in seconds. Alerts can flag a human attendant, allowing them to correct mistakes before claim submission. Automation technology like the Enhanced Claim Status streamlines the revenue cycle by tracking the claims adjudication process in real-time. Instead of submitting a claim and awaiting the payer's response, this technology provides claim statuses within 24 to 72 hours. Step 2: Prevent delays with front-end edits and save time spent in claims adjudication How much time could providers save by correcting front-end mistakes before the claims adjudication process begins? During claims adjudication, payers will compare claims data to payer edits, to make sure billed services are coded correctly. Therefore, providers must keep pace with current coding requirements and the universal, local and payer-specific edits that apply. If claims are not correct the first time, they'll fail the payer's initial automated review, and may be denied or pushed into a queue for manual review by a claims examiner, leading to inevitable delays. Front-end claims editing tools can find errors that might prevent reimbursement, such as missing prior authorization or coordination of benefits codes. Patient Access Curator, Experian Health's latest revenue cycle data curator package, helps healthcare providers eliminate errors quickly on the front-end. This solution uses AI to perform eligibility, COB, Medicare Beneficiary Identifier (MBI), demographics and discovery in a single solution, preventing denials at the front end with a single click, within seconds. Experian Health's ClaimSource® solution allows organizations to implement customized edits and rules tailored to specific payer requirements. These edits help catch errors related to coding, billing, or other aspects of the claim, preventing inaccuracies from progressing to claims adjudication. While the industry average for claims denials is 10% and higher, Experian Health clients who use ClaimSource have a typical denials rate of just 4%. That's one reason Experian Health's ClaimSource solution earned the top KLAS ranking for the second consecutive year. Step 3: Streamline record-keeping and data management Electronic record keeping plays a pivotal role in ensuring accuracy in healthcare claims. These platforms allow centralized storage of patient data, including medical history, treatment plans, and billing information. Electronic record systems can enforce standardized coding practices, ensuring that medical codes used for billing and claims adhere to industry standards. They also maintain detailed audit trails, documenting all changes and updates made to patient records. This level of accountability enhances accuracy by allowing organizations to trace any modifications and ensure data integrity throughout the claims adjudication process. Notably, electronic record-keeping systems seamlessly integrate with healthcare claims management systems. Integration ensures that the information entered into electronic health records (EHR) automatically populates relevant fields in the claim, minimizing the need for manual data entry and reducing the risk of transcription errors. Step 4: Automatically review coding for accuracy Coding errors can result in claim denials and delay reimbursements to providers. For example, manual coding introduces the risk of typos or misinterpretation of the medical record. Because of the complexities of payer requirements, an incorrect procedure or diagnosis code could trigger claim rejection. Some procedures require supporting documentation or pre-verification before treatment. At the same time, ICD-10 (codes for patient diagnosis) and CPT codes (that identify services rendered) undergo regular updates. Failing to stay on top of these coding systems increases the risk of a rejected claim. The solution is to apply AI and automation to improve the chance of claims adjudication success. Two solutions from Experian Health include: AI Advantage™ - Predictive Denials uses AI to spot documentation errors before the claim goes to adjudication. The solution automatically flags claims with a higher potential for denial, allowing the revenue cycle team to fix errors before claim submissions. For claims that have already been denied, AI-Advantage Denial Triage identifies and prioritizes high-value denials, so teams can focus on remits with the highest impact. Denial Workflow Manager allows providers to quickly identify denied claims early in the claims adjudication process. Remittance details show providers the steps necessary to amend the claim quickly for a higher chance of reimbursement. Intelligent data-driven denial analytics spot the root causes of denials, so remedial action can be taken. Step 5: Create clear patient communication channels Clear patient communication channels are essential for preventing errors in healthcare claims adjudication. Incorrect patient information can result in claim denials, causing delays in reimbursement and impacting both patients and healthcare providers. Automated patient outreach technology significantly enhances communication while reducing the likelihood of errors. Solutions like Patient Access Curator also work to capture accurate patient data at registration - all in a single click. Electronic patient portals, powered by automation software, can also solve this challenge. These portals empower patients to update their information directly, ensuring the accuracy of data submitted with claims. Patients can verify and input their demographic details, insurance information, and other relevant data through user-friendly interfaces. Electronic patient portals significantly reduce the risk of errors in patient information by minimizing manual data entry and streamlining the information-sharing process. These tools enhance the efficiency of the claims adjudication process, reduce the likelihood of denials, and promote a smoother experience for patients and healthcare providers. Step 6: Advocate for policy change Moving towards claims adjudication automation with uniform industry standards can save providers and payers time and money. Currently, each payer operates within their unique silo of ever-changing reimbursement requirements. A lack of standardization means providers spend hours checking claims against payer requirements. The first step toward industry standardization requires automation technology to eliminate these time-consuming manual processes. Digital solutions like Experian Health's online prior authorization software update requirements directly from payer websites, giving providers a better shot at submitting a clean claim. Advocating for healthcare policy change toward greater automation and more uniform industry standards is a strategic move that will save time and money and foster a more efficient, transparent, and technologically advanced healthcare ecosystem. This transformation will improve patient care and overall system sustainability. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Improving healthcare claims management with Experian Health Today, nearly 20% of all healthcare claims are denied, and 60% are never resubmitted. That ties up significant revenue in the claims adjudication process. However, better claims management processes can yield reduced denials and faster payments. Experian Health offers a complete ecosystem of tools to deliver cleaner claims and faster reimbursement. This suite of products creates an integrated technology ecosystem with a track record of increasing the speed at which healthcare providers get paid. Find out more about how Experian Health's Claims Management solutions can support a more streamlined claims adjudication process.

Many healthcare providers believe pairing “revenue cycle” with a qualifier like “predictable” is an oxymoron. From healthcare staffing shortages that slow down reimbursement tasks to increasing payer denials, financial regularity can seem like an unattainable goal for these organizations.  The American Hospital Association (AHA) reports over one-half of U.S. hospitals had financial losses in 2022. Another AHA survey shows that 84% of these organizations say the cost of complying with complicated payer policies is climbing. Providers throw an excessive amount of time and staff at chasing revenue, but reimbursement complexities make for anything but smooth financial sailing. How can healthcare providers even out the ebbs and flows of the revenue cycle? Experian Health's suite of revenue cycle management (RCM) solutions can help. Revenue cycle predictability during the life of a claim When it comes to finances, U.S. healthcare providers rarely have an easy go of it. Today, the average life of a claim is anything but average. From registration to collections, hospitals established a new normal over the past decade: Widening gaps between service delivery and reimbursement. How can providers tackle this untenable situation? The answer is two-fold: with technology and at each stage of the life of a claim. Here are three ways healthcare providers can use technology to create reimbursement predictability at each stage of a claim's life. 1. Establish payment accountability at patient registration with price transparency Reimbursement problems begin at patient registration. Healthcare price transparency demands patients understand the cost of care. According to Experian Health's State of Patient Access survey, 81% of patients agreed that an accurate estimate helps them better prepare to pay for their care costs. However, only 31% of patients received a cost estimate before care. There are three significant impacts of this troubling trend: Nearly 40% of patients say they put off needed care due to cost. The number rises to 61% if the patient is uninsured. Patients can't afford to pay for needed care. Currently, 41% of U.S. adults have medical debt. An Experian Health study showed four in 10 patients spend more than they can afford on healthcare treatment. Uncompensated care causes a significant drop in healthcare provider income, which has amounted to almost $745 billion, according to the AHA. Experian Health offers several data-driven solutions to improve price transparency. These tools make it easier for patients to handle their financial responsibilities while helping providers find solutions to help ease their burdens.Patient Financial Advisor creates more accurate service estimates for patients before their procedure. The mobile-first platform offers patients a detailed cost breakdown on their preferred digital device. Patient Estimates is a web-based platform offering real-time service estimates. Blessing Health System uses the tool to provide patient estimates that are up to 90% accurate. The provider increased collections by 58% and credits the software with a 1,200% return on their investment. Patient Access Curator automatically initiates communication with payers to improve coordination of benefits and maximize return. It also automatically identifies missing or incorrect Medicare Beneficiary Identifier (MBI) numbers or errors in patient contact details. This solution also helps providers understand the patient's ability and propensity to pay, allowing these organizations to predict revenue streams after service delivery. Behind the scenes, Experian Health also automates insurance eligibility verification to unlock hidden reimbursements. This software roadmaps the correct coverage, connects to more than 900 payers and verifies insurance coverage at the time of service to improve cash flow and ease patient payment burdens. 2. Reduce claim denials by decreasing manual paperwork errors Claim denials are one of the biggest impediments to revenue cycle predictability. Providers are stuck in an endless cycle of inaccurate payer submissions, rejected claims, and rebilling, creating a chaotic chase for payment long after the service. Today, 35% of healthcare organizations report $50 million or higher in lost revenue due to claims denials. Even worse, Experian Health's State of Claims 2022 report showed that 30% of providers say denials are increasing by up to 15%. According to that data, the top three reasons for claim denials are: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Coding inaccuracies. Experian Health's Claim Scrubber software levels out provider cash flow, creating predictability amidst the chaos. The solution reviews complete claims for errors, generating actionable edits before submission. Claim Scrubber also reviews approved reimbursement rates to prevent undercharging. Transactions process within three seconds and providers reduce the need to rework claims. Experian Health's AI Advantage solution uses the power of artificial intelligence (AI) to evaluate every claim for its propensity to turn into a denial. Instead of submitting claims and hoping the payer will accept them, this solution takes the guesswork out of reimbursement for a more rational, predictable process. The software automatically scans for payer updates to reimbursement requirements that significantly contribute to claims denials. Hospitals like Schneck Medical Center use this tool to streamline the revenue cycle by preventing denials. After just six months, the provider’s denied claims reduced by an average of 4.6% each month. Claim corrections that took up to 15 minutes manually are now processed in less than five. 3. Increase collections efficiency with automation Patients trust their healthcare providers to take care of them. Providers also rely on patients to pay their bills. It's a mutually beneficial arrangement. However, it's also a problem forcing providers to walk a delicate tightrope between caring for a sick patient while still chasing payment for their services. Unfortunately, the increasing cost of healthcare leaves patients on the hook for more than $88 billion in debt. The volume of healthcare payments in arrears is staggering, causing a substantial drain on provider cash on hand. However, technology offers healthcare providers a way to improve the patient collections process. For example, Coverage Discovery impacts the revenue cycle at every stage of the claim: Before providing care, the software scans patient data to determine reimbursement coverage options from Medicaid, Medicare, and commercial insurance. It scans for active insurance 30, 60, and 90 days after care delivery. The tool scans patient data before determining whether the account moves to bad debt collections. A more robust understanding of patient payment options at every stage of claims management allows healthcare providers to forecast reimbursements more accurately, increasing the predictability of the revenue cycle. Collections Optimization Manager provides organizations with actionable insights, so that providers can segment and prioritize accounts by proprensity to pay. This solution increases patient collections by leveraging Experian's data driven segmentation models, and helps providers screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Experian Health's AI Advantage – Denial Triage prioritizes rejected claims based on their yield potential, automating workflows for claims managers so they focus first on the patients more likely to pay. This tool segments denials based on their potential value to help even out the revenue cycle with a faster rate of financial return. Denial Triage expedites A/R by increasing revenue collection per person per hour. Revenue cycles can be more predictable, but the complexities of reimbursement require technology to achieve this goal. Experian Health offers a comprehensive line of revenue cycle management solutions to help healthcare providers maximize collections and improve RCM. Find out why Experian Health ranks Best in KLAS for 2024 in the categories of Claims Management & Clearinghouse and Revenue Cycle: Contract Management, or contact us for a more predictable revenue cycle, better cash flow, and a healthier organization.

Technology has a long track record of improving patient care. But humans are now entering uncharted waters as the latest wave of digital tools impact healthcare clinical and administrative workflows. Technology advancements in artificial intelligence (AI) have spawned a fourth industrial revolution. According to the World Economic Forum, it's a time in history “that will fundamentally alter the way we live, work, and relate to one another. In its scale, scope, and complexity, the transformation will be unlike anything humankind has experienced before.” New developments in AI and automation in healthcare will offer numerous benefits to providers. The impact of recent technology advancements in healthcare is staggering. New AI and automation tools can detect human illnesses faster, monitor patients in the privacy of their homes, and streamline laborious administrative healthcare workflows to save providers up to $360 billion annually. The impact of AI and automation in healthcare is just beginning. Here are three ways these tools can help prevent and reduce claim denials, alleviate staff workloads and improve the patient experience. 1. AI and automation helps lessen claims errors Experian Health's State of Claims Survey 2022 reported that 61% of providers rely too heavily on manual processes and lack the automation necessary to streamline reimbursement. Billions of dollars are tied up in rejected claims; healthcare professionals say up to 15% of their claims are denied. However, many denials are preventable simply by eliminating human error stemming from manual workflows. When paperwork is still done by hand, mistakes in eligibility verification or incorrect insurance information are all too common. Some of the typical reasons for claims denials include data entry errors. Claims are complex, and providers handle most revenue cycle tasks manually, so it's common for incorrect insurance details, eligibility verification problems, or other inaccurate or missing information to make it through to claims submission. Far from being science fiction, the newest AI-powered administrative tools can scan patient claims data to detect errors that lead to denials. Given that diagnostic errors alone cost more than $100 billion and affect 12 million Americans annually, this new breed of AI tools offers providers a way to improve care delivery while lessening the endless hassle of claims denials. AI and automation tools can help eliminate up to errors that lead to denied claims. For example: Patient Access Curator automates insurance eligibility and coverage, scanning patient documentation for inaccurate information. The software uses AI and robotic process automation (RPA) to reduce manual errors. AI Advantage™ works to prevent denials before they happen: AI Advantage -Predictive Denials spots claim errors before submission to the payer. It's an early warning system designed to reduce denials by red flagging claims errors. But it also flags claims that fail to meet payer requirements—even if those requirements have recently changed. 2. AI and automation reduces manual processes and staff burnout Manual processes in healthcare contribute significantly to burnout, which affects nearly 50% of staff. The cost of staff burnout and preventable turnover runs around $4.6 billion annually. However, overworked staff leads to mistakes in manual processes and ultimately claim denials, so the cost of burnout directly affects the revenue cycle.Experian Health's 2023 staffing survey shows 100% of healthcare providers say staffing shortages have impacted their revenue cycle. But staff burnout and turnover affect more than reimbursement—more than 80% say it also negatively impacts the patient experience. AI and automation in healthcare can help alleviate the overwork that many staffers feel. Experian Health offers solutions to automate manual tasks, free up staff time, and reduce the volume of claims denials. ClaimSource® reduces the industry's average claims denial rate of 10% or higher to 4% or less. This software automatically scans claims, payer compliance, insurance eligibility, and patient demographics to spot the errors that lead to denials. Automating claims submission lessens the administrative burden and improves the work/life balance for overburdened staff. AI Advantage - Denial Triage covers any claims that end up rejected, prioritizing claims with the highest rate of ROI for providers. The solution uses artificial intelligence to help staff organize their efforts toward the highest revenue generating opportunities to increase revenue collection. It can lessen workloads and help teams work smarter for a higher return and better bottom line. 3. AI and automation in healthcare improves patient experiences Automation improves the patient journey. Experian Health and PYMNTS research show positive patient experience starts with self-service scheduling and registration. This kind of digital front door puts control back in the hands of patients, who are frustrated by time-consuming administrative processes. Patients have high expectations for better tech experiences throughout their healthcare encounters. Experian Health offers solutions that give customers exactly what they demand. For example: Patient Scheduling software allows 24/7 online access to appointment setting tools. In addition to making a more convenient and accessible scheduling process, this tool reduces the time it takes to set an appointment by 50%. The benefits for healthcare providers include a higher patient show rate (89% on average) and higher patient volumes (32% more patients per month). Patient Financial Advisor offers seamless, automated service estimates that go straight to the patient's favorite digital device. The tool creates a transparent payment process to help patients understand their treatment's cost and payment options. Patient Financial Advisor integrates with a secure online payment portal. These tools establish financial accountability up front while eliminating unnecessary surprises that affect the provider/patient relationship. Benefits of AI and automation in healthcare AI and automation in healthcare are changing how patients experience care delivery, how providers interact with their customers, and how clinicians manage getting paid. The benefits of using these tools include: Faster and more accurate patient diagnoses. Fewer patient readmissions and more proactive care management. Streamlined administrative tasks to reduce claims denials and improve the revenue cycle. Experian Health offers a suite of technology solutions, including a revenue cycle data curator package, to help providers get paid faster, free up staff time, and improve the patient experience. These solutions can help healthcare organizations achieve their goals by harnessing the latest AI and automation technologies to work smarter. Connect with an Experian Health expert today.

The ecosystem of healthcare revenue management involves the entire lifecycle of medical billing. It starts with patient scheduling to encounters, then moves to coding and medical billing. However, understanding the basics of medical billing isn't just for the back-office team: it's vital for front-office staff too, especially those dealing directly with patients. Many patients arrive with coverage from multiple payers and high deductibles, which makes claims and collections processes increasingly complex. Providers that get the billing basics right can deliver a better patient experience while setting themselves up for financial success. Discover the key steps in the medical billing cycle and learn how healthcare providers can improve efficiency, streamline collections, and increase profits from appointment scheduling to payment completion. What are medical billing basics? Medical billing is about ensuring providers get paid for the services they provide, whether that be submitting claims to payers or invoices to patients. The workflow may be broken down into three phases: Front-end medical billing: The process starts with patient intake and registration. During this process, staff collect relevant information about the patient, their coverage, and their diagnosis and treatment. They must know what payers require in terms of claims documentation so they can collect the right data upfront. At this time, staff will also inform patients of their financial responsibility, so patients are prepared for their upcoming bills, or can make payments before service.yr45 Back-end medical billing: This part of the cycle occurs after the encounter. Once it's documented, medical coders and billers use information obtained during registration to figure out who pays what toward the final bill. Coding rules and documentation requirements vary considerably, depending on payer type (commercial, government or self-pay) and individual payer policies, so many organizations use automation and artificial intelligence to increase medical billing accuracy and minimize denials. These tools also support the claims adjudication process. Patient collections: If there are any remaining balances after insurance reimbursement, healthcare organizations generate bills for patients. These detail the services provided, the amount already covered by insurance, and any outstanding balances owed by the patients. Increasing numbers of self-pay patients with high deductibles put new pressure on patient collections, and managing the workflow is challenging without technology, data and analytics. Healthcare organizations struggle to collect more than one-third of patient balances greater than $200, which makes understanding how to improve medical billing is essential. What’s the relationship between the medical billing revenue cycle, successful billing and patient collections? Within the medical billing revenue cycle, there are opportunities to maximize efficiency and accuracy, with tangible benefits for staff, patients, and those with an eye on profits. These opportunities rely on bridging the gaps between the three phases above with reliable data and integrated workflows. Some strategies and tools include: Find missing coverage: Proactively identifying billable government and commercial coverage is a huge relief for patients, who won't be billed for amounts that could be paid via alternative sources. Additionally, providers are more likely to be reimbursed. Coverage Discovery uses multiple proprietary databases to scan for missing or forgotten coverage throughout the patient journey. In 2023, this solution tracked down billable coverage in 32.1% of patient accounts, resulting in more than $25 million in previously unknown coverage. Tailored payment options for patients: Providing upfront pre-service cost estimates for patients gives them clarity about what they'll owe so they're less likely to be shocked when they receive their bill, and are more likely to pay on time. Patient Payment Estimates generates quick, accurate pricing estimates along with a clear breakdown of how the costs have been calculated and secure links to instant payment methods. Helping patients find financial assistance: From the first encounter, patient financial data can be interrogated to determine whether they may be eligible for financial assistance. Getting them on the right pathway from the start means they're less likely to delay and default on bill payments. Flexible payment plans: Research from Experian Health and PYMNTS shows patients are eager for flexible ways to pay. Rigid and protracted processes are inconvenient for patients and often end up multiplying medical debt, which is bad news all round. Simple self-service tools can meet patients where they are and help them manage their bills, whether they prefer to pay in full and up front, or they need to break it into more manageable instalments. This reduces payment delays and lessens the medical debt burden on all parties. Streamlined, secure payments: PaymentSafe® accepts secure payments anywhere, anytime, using eChecking, debit or credit card, cash, check and recurring billing – all through a single, easy-to-use web tool. Every patient encounter becomes an opportunity to collect payments with minimal fuss. Automated patient outreach: An easy win with automation is to issue appropriate reminders to patients about upcoming and overdue payments. Automated dialing and texting campaigns mean patients get relevant information through convenient channels, and staff can focus on more complex collections cases. Strategic collections management: Segmenting and prioritizing collections accounts based on propensity to pay allows staff to spend their time where it matters most. Automation and data analytics can be used to route accounts to the correct pathway, resulting in a more compassionate patient experience, better use of resources, and increased collections overall. Identifying inefficiencies in medical billing To select and implement the above strategies and RCM medical billing solutions, it's important to identify where inefficiencies and gaps are in the process. Some questions to consider are: Are we relying too heavily on manual entry in our billing activities? What are the root causes behind our medical billing errors? Are our tracking and reporting efforts throughout the billing lifecycle? How accurate are our payment estimates and eligibility verification processes? Are our current payment acceptance practices and plans effective? How successful and compassionate are our patient outreach efforts? By assessing each area, providers can pinpoint opportunities to simplify the medical billing workflow and use revenue cycle management technology to accelerate collections. Optimize patient collections with the Collections Optimization Manager One specific example of how healthcare organizations can improve patient collections is with Collections Optimization Manager, which uses data analytics to manage the medical billing basics and customize collections strategies. The platform streamlines patient collections by screening out bankruptcies, deceased accounts, Medicaid and other charity eligibility, so staff don’t waste time chasing payments. Remaining accounts are grouped and routed to the most appropriate pathway, so they can be dealt with quickly and effectively. Case study: See how St. Luke's University Health used Collections Optimization Manager to collect an additional $1.2 million in average monthly collections,, in the midst of staffing shortages. Explore more ways to use Collections Optimization Manager to streamline the medical billing basics and accelerate patient collections.

Claims denials are a thorn in the side of any healthcare organization. Even with claims denial mitigation tools and processes in place, denials are growing. In Experian Health's State of Claims 2022 report, 30 percent of respondents said denials increased between 10% –15% annually. To combat rising denials, ensure faster reimbursements, and improve the revenue cycle, healthcare providers need new claims technology that focuses on efficiency. In this post, learn about the common challenges in traditional claims processing and how to implement automated or AI-based claims management technology to drive healthcare revenue cycle efficiency. Challenges in traditional claims processing When it comes to reimbursement, the odds of being paid do not always favor the healthcare provider. The complexity of claims makes for labor-intensive workflows in traditional reimbursement processing. Data is often culled from multiple systems, including electronic health records (EHRs), paper files, diagnoses, test results, insurance verification, and more. Providers lacking a streamlined set of workflows supported by claims technology, experience errors that can lead to denied claims. Three of the most common challenges in traditional claims processing include missing or incomplete claims information, payer-related problems, and a need for more staff, which slows down processing productivity. 1. Missing or incomplete claim information Missing data is also a huge issue in traditional claims processing. In fact, missing or incomplete data is one of the top reasons for claims denials, particularly in the area of prior authorization. These mistakes often begin upstream at the first point of patient contact and, if not corrected, snowball toward the inevitable denial. Compounding the problem is that disparate healthcare systems and workflows make it increasingly challenging to collect all the data effectively. The larger the healthcare provider, the more touchpoints for claims processing, creating back-and-forth workflows that can lead to miscommunication or the loss of information. 2. Payer-related challenges Just keeping up with changes in payer requirements is a full-time job. Payers often change reimbursement requirements, and providers aren't aware of these new adjudication rules. It requires strict monitoring of all payers, which is impossible for organizations to manage. Prior authorizations are also increasingly burdensome for providers to handle. An AMA survey found that 88 percent of physicians said these burdens were high or extremely high. Providers estimated they process 45 prior authorizations weekly, equivalent to 14 hours of staff time. 3. Reduced or new staff can't keep pace Another challenge is not having the workforce necessary to review claims to identify errors. Workforce shortages continue to impact every healthcare area. The chronic challenge of high workloads and short staffing means most teams work as quickly as possible, leading to preventable mistakes. Without advanced claim technology, staff manually handle heavy workloads, which is driving denials through the roof. The lack of staff also affects traditional claims processing by slowing denials resubmissions. A less efficient denials management process directly affects provider cash flow, creating more delays in getting paid. Resolving these challenges requires modern, advanced claims technology powered by automation and artificial intelligence (AI). By leveraging this technology for claims management, healthcare providers can solve these problems for greater reimbursement efficiency and a better bottom line. Best practices for implementing AI-based claims management technology Experian Health data shows 51% of healthcare providers currently leverage some software automation. However, only 11% had integrated AI technology into their organization. Mounting evidence suggests preventing healthcare claims denials starts with innovative AI-driven claims management technology. AI and automation applied to a claim technology solution can prevent claims denials on the front-end of the patient encounter and improve denial management on the back-end of the process. When evaluating how to implement advanced claim technology, consider these best practices: Start by identifying the pain points in existing claims processing workflows. Review claims denials and mitigation data and talk with existing staff to develop this list. If the organization leverages legacy reimbursement tools, consider how efficiency gaps affect the organization. Consider organizational goals and objectives for replacing manual workflows or upgrading legacy claims management technology. As the organization explores the benefits of advanced claim technology featuring AI, develop use cases for employing these tools for more effective claims management. Compare new product features to these real-life scenarios. Seek stakeholder feedback. All technology rollouts require significant buy-in at every level in the organization. Don't miss engaging with the boots-on-the-ground workforce using the claims technology Ensure the organization has the infrastructure to support the new platform long after it goes live. When evaluating new digital tools, keep these things in mind: Select AI-based claims technology that utilizes workflow customization to manage the entire reimbursement cycle. Seek out a solution that automatically reviews each line in a claim to check for errors so that first submissions are accurate. Leverage a system with automation features that eliminate error-prone manual processes. Choose a platform that enables denial prediction and mitigation. Find a product with denials workflows and enhanced claims monitoring functionality. AI technology is the game-changer for healthcare's skyrocketing claim denial challenges. These new tools deliver immediate value to an increasingly disjointed and complex reimbursement process. With the right technology, healthcare providers improve the claims processing efficiency to get paid faster. Transformative impact of Experian Health's advanced claims technology Experian Health is a leader in digitally transforming traditional claims processing. AI-powered technology can increase staff efficiency at every stage of the claims management process. Experian Health's AI Advantage™, part of the Best in KLAS ClaimSource® platform, is transforming provider claims processing. This software reduces the need for additional staff by automating manual tasks. It lessens the burden on existing teams by lightening their claims processing and denials management workloads. AI Advantage has two primary solutions affecting every stage of the claims management process: Predictive Denials identify undocumented payer rules resulting in new denials. This AI-driven solution finds the claims most likely to fail, flagging them back to payment processing for correction before they're even submitted to the payer. Denial Triage manages prioritization of denied claims. Advanced algorithms in this solution identify and flag denials based on their potential value. Organizations maximize their returns on denied claims by focusing on the resubmissions with the highest financial impact. It removes the guesswork from reworking claims, lessening staff workloads by eliminating time wasted on low-value cases. Another solution, Patient Access Curator, uses AI and robotic process automation to enable healthcare staff to capture all patient data at registration, with a single click solution that returns multiple results - all in 30 seconds.  Experian Health's automated and AI-fueled advanced claim technology improves provider reimbursement efficiency at every stage of the process. The efficiency-related benefits of AI for claims management include avoiding denials, accelerating denial mitigation, and getting paid faster. To explore these tools—and their extraordinary ROI, contact the Experian Health team today.

Labor shortages and the uptick in claim denials are undoubtedly putting heavy financial strain on healthcare providers. Could automated claim denial prevention help ease the pressure? In a recent webinar, Jason Considine, Chief Commercial Officer at Experian Health, and Jordan Levitt, Co-founder at Wave HDC (recently acquired by Experian Health), discussed strategies to tackle denials head-on in the coming year. This article summarizes the key insights, including a new automated one-click denial prevention tool that shifts denials management to the front end of the revenue cycle. 5 revenue cycle challenges causing claim denials and strained margins To start, Considine opened the webinar with a discussion of the root causes of denials. These often originate during registration, and for many providers, “registration and data integrity continue to be a problem.” A fifth of denials are attributed to just five key issues: Coordination of benefits (COB) denials, which account for a major portion of denials as more patients have secondary and tertiary coverage; Contingency fees, which eat up margins in exchange for information that providers should be able to obtain themselves during registration; Labor costs, which can increase with labor-saving automations that push manual input downstream; Epic plan mapping, which becomes increasingly complex and error-prone as payer requirements evolve; Transactional pricing, where “pay-per-click” pricing models disincentivize providers from using registration tools to find patient information during registration. These interrelated issues should be solved with one up-front revenue cycle management (RCM) solution, rather than piecemeal fixes that are implemented later. According to Considine: “Vendors tend to offer ways to solve these problems after the patient leaves, but really we should have gotten the right information right up front. Pushing problem-solving downstream means you need more people to manage these solutions, you've got more vendors to manage, and you end up staffing denial management departments and throwing more people at the problem.” Shifting from denial management to denial prevention Part of the challenge is the sheer volume of patient information that must be collected from the start. Staff interact with multiple systems to collate, check and coordinate data on eligibility, COB, Medicare Beneficiary Identifiers, demographics and coverage. Many of these data points can be points of failure if the wrong information is captured and penetrates the rest of the system. This makes patient access the perfect place to solve the denials problem. Levitt says this is exactly what Wave HDC set out to do when they developed the technology that underpins Patient Access Curator. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within two to thirty seconds.” Patient Access Curator prevents denials by capturing all patient data at registration through a single click solution that returns multiple results in less than a minute. It's fast because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer. This means data can be transferred easily between interfaces. Levitt explained how the tool builds a “perimeter defense against bad data,” by ensuring data accuracy from the start. Bad data is less likely to propagate through the system, which reduces the risk of denials. As a result, clients using the tool have been able to reduce contingency volume by over 60%. Introducing the next generation of smart RCM technology Many organizations are investing in staffing to address claim denials, but this approach is not effective in the long run. Levitt described how preventing denials calls for technology that's built for today's challenges. “Most tools out there are built to manage the problems of the last twenty years. But twenty years ago, we didn't really have COB issues. Patients were either insured or uninsured. Now, some are over-insured and some are under-insured. You see more patients come in with one insurance card in their hand, but with two, three, or four other coverages. It's much more complex. Patient Access Curator makes it simple by bundling all the transactions into one.” The technology uses artificial intelligence, in-memory analytics, and robotic process automation to verify eligibility and COB, find and fix patient identifiers, check contact information, and generate information about the patient's propensity to pay. And the result? Providers can simplify denials management even as the insurance and operational landscape becomes more complex. Watch the webinar to hear the full discussion and find out more about how Patient Access Curator helps healthcare organizations capture accurate patient information at registration with a single click.

There is growing concern that the healthcare industry needs more clinical and administrative staff to handle care demands. The crisis affects patients beyond treatment delays or lower care quality. Staff shortages in the revenue cycle create problems with patient engagement, billing, and collections. A recent Experian Health survey reveals unanimous concerns among providers about the challenges posed by workforce shortages. But what are the root causes of staffing shortages in healthcare? Is there a remedy for healthcare organizations struggling to find the talent they need? This article dives into the survey findings and the ways healthcare providers can address staffing shortages effectively. Finding 1: Staff turnover is a significant cause of healthcare staffing shortages. 80% of providers report turnover between 11-40%. Nearly one in 10 say turnover is between 41-60%. The causes of staff shortages were evident before COVID. A rapidly aging Baby Boomer population and limited availability of training in areas such as nursing led to predictions that looming staff shortages were on the horizon. The pandemic exacerbated the situation, leading to a mass exodus of workers and The Great Resignation. Some reports show healthcare lost 20% of its workforce, including 30% of nurses. Today, the average hospital turns over one-quarter of its staff annually, an increase of more than 6% from the prior year. As a result, the State of Patient Access 2023 reported nearly 50% of providers say access to care is worsening. Simultaneously, healthcare is bogged down with administrative tasks. Increasing evidence shows providers must turn to automation software to decrease human workloads and stretch small teams further. These automated tools can: Create a seamless registration process for patients to improve care access, reduce no-shows, and reduce provider administrative burdens. Provide 24/7 patient scheduling and put patients in charge with self-scheduling options Automate patient outreach to increase collections and improve communication. Improve claims management, reduce denials, and free up existing staff from manual tasks. Automation can improve the work-life balance of healthcare staff, potentially closing the revolving turnover door, one of the most significant causes of staff shortages. For example, IU Health implemented automated guided scheduling, which helped scale their operations, reduce scheduling errors and improve staff efficiency. Finding 2: Finding and hiring staff is an undue burden for healthcare providers. 73% of respondents said finding qualified staff is difficult. 61% reported that meeting entry-level staff's salary expectations is a challenge. Healthcare organizations feel the staffing crisis at every level. A recent Medical Group Management Association (MGMA) poll cited the difficulties in hiring revenue cycle staff: 34% of respondents stated hiring medical coders is their biggest challenge. 26% stated billers were difficult to find. One-third said finding schedulers and prior authorization staff is hard. Other hiring challenges included revenue cycle management (RCM) managers. When and if healthcare providers find staff, bringing them into the fold is costly. Experian Health's staffing survey showed most organizations struggle to meet the salary expectations of even the least experienced members of their teams. The causes of staff shortages can be remedied by leveraging new artificial intelligence (AI)-powered tools. Tools like AI Advantage™ can automate and transform claim denials management, a problem costing healthcare providers around $250 billion annually. Experian Health's State of Claims 2022 survey showed the most common causes of denied claims include: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Inaccurate medical coding. AI Advantage reduces denial rates by scrubbing claims and flagging errors before submission. After claim submission, the software prioritizes the most high-value denials for correction to maximize revenue generation. Organizations like Schneck Medical Center use these tools to reduce denials by 4.6% each month. The facility also increased the speed of claims submissions. Tasks that used to take 12 to 15 minutes to rework now process in less than five minutes, lessening the need for hiring more staff and improving the workloads of their existing team. Finding 3: Burnout is a top contributor to staffing shortages. 53% of poll respondents said staff burnout is a key cause of the current staff shortage. 48% said the new expectation for schedule flexibility and hybrid work models also contributes to the healthcare workforce shortage. Burnout is one of the most significant causes of staff shortages impeding high quality care and wreaking havoc on the revenue cycle. The latest data shows the percentages of clinical and administrative burnout in healthcare is approaching or exceeding 50% in most job categories: 56% of nurses report burnout symptoms. 54% of clinical staff. 47% of doctors. 46% of non-clinical staff. Cost-cutting and increasing care demands have led to increasing fatigue in healthcare staff. But technology exists to automate back office functions that could free up staff time. For example, organizations like Kootenai Health saved close to 60 hours of staff time in over 8 weeks by automating the presumptive charity process Patient Financial Clearance. Stanford Health used Collections Optimization Manager to cut 672 hours each month from overburdened back office staff. The COVID pandemic also changed expectations about how and where Americans should work. Remote work became normal; three years post-COVID, 58% of the American workforce report working remotely at least one day a week. The same data also shows that when workers have the chance to work virtually, 87% take it. Healthcare is not immune to the desire for more schedule flexibility. Becker's Hospital Review states, “Many workers desire the ability to work remotely, even if they only get the option a few days a week. Flexibility allows people to maintain work-life balance—and in a high-burnout field like healthcare, balance can be crucial.” Surveys show 31% of healthcare roles are remote full-time while 14% offer this flexibility part-time. The problem is that many healthcare positions cannot allow this flexibility—and the industry competes with others that do. To remain competitive, healthcare organizations must embrace technology to offer work flexibility. Cloud-based digital technology is beneficial in areas like the revenue cycle. For example, automated technology from Experian Health can: Use advanced analytics to streamline workflows. Facilitate patient self-service. Minimize staff time spent on manual tasks. AI-powered automation tools can lessen staff burnout by allowing them to work smarter. These tools provide the workforce with the scheduling flexibility they desire. Eliminate the causes of healthcare staffing shortages with better technology AI and automation technology in healthcare can lessen worker fatigue, lighten workloads, and give administrative workers the schedule flexibility they demand. Experian Health offers healthcare providers better technology to improve the lives of their staff, increase patient satisfaction, and generate more revenue. Download the survey or connect with an Experian Health expert today to learn how we can help your organization tackle the causes of healthcare staffing shortages effectively.

In a strategic move that will take claims management to the next level, Experian Health recently acquired Wave HDC, a healthcare technology company specializing in AI-guided data capture and curation. The acquisition brings together the two companies' capabilities to offer healthcare organizations faster and more accurate healthcare coverage identification. With this acquisition comes Patient Access Curator, a new solution that uses artificial intelligence (AI) to revolutionize the claims management process. Tom Cox, President at Experian Health, says, “With our vast clearinghouse data resources and Wave HDC's technology and expertise in insurance data capture processes, Experian Health now offers the best eligibility and insurance identification products in the market.” This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds. Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. Watch now Prevent denials on the front end Managing claims effectively – or more specifically, preventing denials – is one of the biggest challenges for providers. In a 2022 survey by Experian Health, 72% of respondents said reducing denials was their top priority, citing reasons including payer policy changes, reimbursement delays, and a rise in the number of errors and denials. Most issues that lead to denials crop up early in the revenue cycle, when information is missed or captured incorrectly during patient registration. For this reason, it makes sense to focus denial prevention strategies on the front end. With so much data to capture, manual strategies are bound to stumble. Unfortunately, many digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility and check for any billable coverage that might have been missed. Experian Health's industry-leading claims management products are designed to simplify these processes. The integration of Wave HDC's AI-powered data capture technology strengthens that offer with capabilities previously not available. As Cox says: “Our mission is to simplify healthcare, and this move allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” For Jordan Levitt, co-founder of Wave HDC, the merger is a chance to bring their unique technology to more healthcare organizations. “We believe this integration will have a powerful impact for the healthcare industry, improving financial solvency and efficiencies for providers through more accurate medical billing, resulting in potentially more reimbursement, faster.” Introducing Patient Access Curator: Claims management in a single click Wave HDC's technology captures and processes patient insurance data at registration using an “if-then” logic that returns multiple data points from a single inquiry, in 30 seconds. Through Patient Access Curator, registration staff can leverage this technology to collect and verify much of the information they need to compile an accurate claim, with just a single click. In a matter of seconds, they'll have a comprehensive readout of the following: Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps; Coordination of Benefits (COB): Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing; Medicare Beneficiary Identifiers (MBI): PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support; Insurance discovery: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches; Demographics: Lastly, but by no means least, the platform can quickly check and correct patient contact information. Providers can hear more about shifting denials management to the front end of the revenue cycle with Patient Access Curator on a recent on-demand webinar hosted by Jordan Levitt and Jason Considine, Chief Commercial Officer at Experian Health. On the webinar, Levitt explains that Patient Access Curator achieves such speedy results “because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer.” This means data can be transferred easily between interfaces. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within thirty seconds.” Maximize dollars, minimize workload Patient Access Curator moves away from manual methods and verifies eligibility and coverage automatically, quickly and accurately. But the platform promises more than efficiency; with this technology, Wave HDC has prevented denials of over $1 billion since 2020. At a time when revenue cycles are under increasing pressure from changing payer rules, labor dynamics and operational constraints, the new integration offers a long-awaited boost to both reimbursement rates and productivity. Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us