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The growing shift from inpatient to outpatient care continues. The U.S. ambulatory services market was estimated at USD 289.5 billion in 2023 and is projected to grow at a CAGR of 5.38% from 2024 to 2030. A Deloitte study notes that the gap between inpatient and outpatient revenue has been closing for two decades. But what's driving this boom? Clinical advances, patient demand for lower-risk and lower-cost options and payer pressure all play a role. New technologies, like advances in orthopedics, allow more procedures to be performed at outpatient service centers instead of costly hospital settings. Free-standing ambulatory surgery sites are expected to see a 14% volume boost over the next decade as more service lines, like cardiovascular and neurosciences, begin to shift procedures from inpatient to outpatient facilities. The ongoing growth in outpatient services presents a unique opportunity for revenue cycle leaders to use technology to improve outpatient revenue—and the overall patient experience. Grow outpatient revenue with more digital care Patients want a better experience at every step of the patient journey. They want to see their doctor faster, manage appointments online and understand how much it costs—with as little red tape as possible. A lack of streamlined patient access and transparency often results in no-shows, a rise in claims denials, wasted staff time and patient complaints. However, by opening the digital front door, providers can give patients the self-service tools they crave, improve the care experience, keep outpatient schedules full and increase revenue. Additionally, providers can use technology like artificial intelligence (AI) to lower claim denial rates. Here are five strategies to increase outpatient revenue in 2025. 1. Make patient access simple Patients want to see their doctor faster. In Experian Health's latest State of Patient Access survey, eight in ten patients who reported being unhappy with their provider experience cited waiting for an appointment as a top complaint. When trying to schedule, patients are also frustrated by the friction that comes with complex processes, clunky technology systems and sparse provider communication. Outdated manual workflows, staffing shortages and lack of staff training often result in challenges for both patients and providers. Improved patient access is at the heart of patient-centered healthcare. Technology designed to put the patient in control, like online patient scheduling and digital patient intake tools, offer continuous patient engagement, optimized scheduling, and streamlined administrative processes. By leveraging modern patient access solutions, providers can improve patient experiences and alleviate the impact of staffing shortages. 2. Reduce appointment no-shows Missed appointments cause headaches for patients, providers, and revenue cycle managers. Online scheduling and mobile registration are also top of mind for patients. In Experian Health's State of Patient Access 2024 survey, 89% of patients said they wanted self-service scheduling and 85% reported a dislike for filling out repetitive intake paperwork. Online patient scheduling software puts patients in the driver's seat, providing convenient and secure 24/7 access to book, reschedule, and cancel appointments on their own time. Solutions like Patient Schedule sync seamlessly to an organization's scheduling rules, and patients receive automated appointment reminders by text or IVR. On average, providers that use Experian Health's scheduling solution experience an 89% show rate, a 50% reduction in scheduling time, and a 32% increase in patients per month. Patient intake tools like Registration Accelerator simplify mobile registration with a streamlined text-to-mobile experience. Once registration is complete, automated returns of forms, patient-check-ins and demographic information ease the burden on staff. 3. Help patients prepare for outpatient costs Patients need a clear breakdown of their financial responsibility before receiving care. Without it, they may be unable to prepare for care costs appropriately. While hospitals are now required to share detailed pricing for at least 300 common procedures, confusion around a patient's actual financial responsibility still persists. More than half of patients report turning to their provider for help understanding what insurance covers. Digital solutions that provide accurate, upfront estimates empower patients. More than eight in ten patients say pre-service estimates help them prepare for the cost of care. Patient Payment Estimates provide upfront, real-time estimates of what a patient will owe. Providers can offer convenient and secure payment links, and allow patients to pay their bills online or see customized payment plans. Outpatient providers can further maximize the chance of reimbursement by running health insurance coverage checks across the entire revenue cycle. This can help find billable coverage that may have been forgotten and give patients greater certainty about what they'll owe. 4. Automate healthcare collections Collections are often a major challenge in the outpatient revenue cycle. Outpatient procedures can be costly, even with insurance, leaving patients responsible for potentially large bills. Automating healthcare collections allows for faster, more efficient, and more compassionate collections. Tools like Collections Optimization Manager helped Novant Health achieve an overall recovery rate of 6.5% and increase revenue and cost savings to a rolling average return on investment of 8.5:1. With automated tools like Patient Financial Clearance, providers can assess patients' ability to pay and assign them to an appropriate financial pathway. This allows patients to quickly get the assistance they need while freeing up valuable staff time. 5. Streamline claims to increase outpatient revenue Denied claims continue to be problematic for providers. In Experian Health's State of Claims 2024 report, which surveyed 210 healthcare revenue cycle leaders, nearly three-quarters of providers feel claims denials are increasing, while 67% feel getting paid is taking longer. Claims management software can help end the cycle of denials. However, around half of providers still use a manual claims review process, and only 28% feel confident in their understanding of automation, machine learning and AI. Adopting automated and integrated healthcare claims management solutions can reduce errors, prevent undercharges, and ensure a higher first-pass payment rate. Tools like Experian Health's ClaimsSource® simplify the entire claims process, while Claim Scrubber helps providers submit more accurate claims. Digital solutions can also automate claim status monitoring and eliminate manual denial processes. Implementing AI tools to interpret past claims data and recommend next steps can improve outpatient claim denial statistics. Tools like AI AdvantageTM look at past payer behavior and historical claims data to predict and prevent denials. AI Advantage's two components, Predict Denials and Denial Triage, help providers respond to growing denial challenges by identifying claims with a high likelihood of denial before submission, and focus on remits that have the most impact. See how: Find out more about how Experian Health's revenue cycle management solutions can help healthcare organizations increase outpatient revenue, keep pace with growing patient volumes, improve patient satisfaction and boost their bottom lines. Learn more Contact us Contact Experian Health Complete the form below to be connected with a member of our Sales team. For Customer Support, including password resets, please visit our Support page.

According to Experian Health's State of Claims 2024 survey, missing coverage is the top reason for healthcare claim denials for almost a fifth of providers. However, the issue isn't just about whether a patient is insured — four in ten providers worry about insurance companies paying out even where patients have active coverage. Constantly changing payer policies can result in altered or expired benefits, leaving providers scrambling to secure alternative sources of payment. That's why many providers are turning to automated health insurance discovery to find missing coverage and catch outdated policies early. This article looks at how coverage discovery software helps healthcare organizations address some of the most stubborn pain points in the revenue cycle. What is health insurance discovery? When a patient comes in for care, one of the first jobs is to figure out exactly what insurance they have — if any — and what it covers. Health insurance discovery is the process of checking whether the patient has active insurance and confirming details of that coverage, such as payer name and plan type, to ensure the cost of care is billed to the correct payer. If a patient has multiple active plans, the provider must also determine how much should be billed to each payer and in what order. How does it work? Ideally, coverage discovery occurs pre-service, but it can occur later if a claim is denied, and alternative coverage sources must be found. The main steps in the process include: Collecting insurance details when patients schedule or check in Checking with insurance companies to confirm that coverage is active and will cover planned services Cross-checking payer databases to ensure no coverage is missed Considering a patient's eligibility for Medicaid or other charity support Coordinating benefits for accurate billing Benefits of automated health insurance discovery for providers While respondents to the State of Claims survey are reasonably confident about their coverage discovery processes, the actual outcomes are less robust. Eligibility checks are taking longer and errors are on the rise. Only 54% of providers believe their claims technology can meet current revenue cycle demands. Automation offers a reliable and adaptable solution to bridge the gap between front-end checks and back-end claims management. Here are a few ways automated health insurance discovery sets the stage for smoother claims submissions and revenue cycle performance: 1. Maximize reimbursement by finding missing coverage quickly Challenge: Patients don't always provide complete insurance information, which can cause providers to miss out on opportunities for reimbursement. How automation helps: Automated health insurance discovery digs deeper than manual processes to find any coverage that may have been missed or forgotten. Experian Health's Coverage Discovery® solution combs through multiple proprietary databases, including employer information, historical search information, registration history and demographic validation to proactively identify billable Medicare, Medicaid, and commercial coverage. With minimal patient details, it finds additional sources of primary, secondary and tertiary insurance instantly. In 2023, Coverage Discovery tracked down previously unknown billable coverage in a third of patient accounts, resulting in more than $25 million in found coverage. 2. Reduce the manual workload Challenge: Staff spend too much time calling payers, logging into portals and manually entering patient data. This is time-consuming and error-prone, especially when one in four resubmissions are worked on by a different person than the one who originally processed it. How automation helps: Automation eases the admin burden by handling repetitive aspects of insurance verification behind the scenes, freeing staff to focus on more complex tasks. Coverage Discovery saves staff time by continuing to check for health insurance throughout the patient journey, and not just at registration. This final post-service check is vital to detect discrepancies that could lead to denied claims. Staff can also automate the self-pay scrubbing process to further reduce the risk of errors. As providers continue to feel the squeeze from staffing shortages and rising operating expenses, any move to reduce costs while bringing in more revenue is to be welcomed. 3. Prevent eligibility issues Challenge: Providers often only discover that active benefits have changed after the claim has been submitted. That's too late. For 43% of providers, it takes at least 10 more minutes to check eligibility when initial checks are incomplete. How automation helps: With automation, providers can run real-time eligibility checks, ensuring that changes to the patient's benefits are caught early so claims aren't denied due to outdated information. Experian Health's new Patient Access Curator uses artificial intelligence-based data capture technology to return accurate information from multiple sources with a single click. It automatically interrogates data from more than 270 payer responses, including active and billable coverage, plan level detail, chaining and primacy, so providers can verify eligibility and more in an instant. 4. Reduce claim denials and rejections Challenge: Incorrect or incomplete insurance information results in errors on claims forms or claims sent to the wrong payer, which causes denials, delays and rework. How automation helps: Automated discovery ensures that the correct payer and coverage information is attached to claims, reducing the likelihood of denial. This solves one of the most frustrating parts of coverage discovery, making the process faster, more accurate and less reliant on manual effort. Read more: How to leverage AI and automation to minimize healthcare claim denials 5. Improves the patient experience Challenge: Patients are often confused about their coverage status and worried about whether their healthcare costs will be met by their insurance provider. Medicare beneficiaries, in particular, report difficulty understanding and comparing plan options, leading to potential gaps in coverage. When healthcare providers fail to catch errors or gaps in their information, this erodes trust and negatively impacts how they feel about their experience. How automation helps: By correctly identifying coverage and verifying benefits eligibility, automation allows providers to give their patients early certainty about how their healthcare costs will be covered. Patients are less likely to receive unexpected or incorrect bills, which prevents delays and disputes. Automated tools can go a step further to improve the patient experience by guiding patients toward additional support and payment plans. For example, Patient Financial Clearance identifies patients who may be eligible for Medicaid or charity assistance, and identifies appropriate payment plans for anyone with an unmanageable self-pay balance. Case studies: See health insurance discovery in practice How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks How UCHealth secured $62M+ in insurance payments and saved $3.5M+ in 2022 with Coverage Discovery How Luminis Health used Coverage Discovery to find $240K in billable coverage each month Learn more about how automated health insurance discovery helps providers reduce claim denials, improve cash flow and deliver better patient experiences. Learn more Contact us

The denial challenge is getting tougher. In Experian Health's latest State of Claims 2024 survey, almost three-quarters of healthcare administrators agree that claim denials are increasing. The majority also agree that difficulties with claims—like reimbursement times, errors, and payer policy changes—are becoming more common. It's no surprise that denial prevention is a priority for 84% of respondents. However, many organizations still focus on reactive strategies, like working harder with denial management teams or appealing claims once the denial comes through. These efforts have their place, but they only address the problem after it occurs. It's a time-consuming, costly and ultimately inefficient way to face the denial challenge overall. A better approach is to figure out how to prevent claim denials in the first place. This article looks at how to build a proactive denial prevention strategy using automation and artificial intelligence (AI), to streamline claims processing and nip denials in the bud. Understanding denial prevention in healthcare Preventing denials starts with understanding the “ins and outs” of the claims process, particularly payer requirements. Denials occur when a payer refuses to reimburse a provider for services rendered, often due to avoidable coding errors, missing documentation or procedural mistakes. When that happens, providers are left to rework the submission or look elsewhere – most likely to the patient – to fill the funding gap. Many are simply written off to bad debt. To avoid receiving an 835 file with the dreaded claim denial notice, providers must focus on the root causes of denials and get ahead of the pitfalls. The importance of claim denial prevention With denial rates exceeding pre-pandemic levels, 42% of survey respondents say the economy and declining consumer confidence make payer reimbursements more urgent. While financial stability is the obvious driver for getting claims right the first time, denial prevention also improves operational efficiency and reduces the billing and coding staff workload. Denials are frustrating for patients and staff. When claims are processed correctly the first time, providers avoid delays and billing complications and reduce patient stress over unexpected costs. Preventing denials is critical for maintaining trust and ensuring patients feel secure about their financial obligations. How to prevent claim denials Denial prevention strategies should start with addressing the underlying causes of denials. Here are five denial prevention strategies to consider: 1. Improve data accuracy from the start Garbage in, garbage out. If patient information, insurance eligibility, prior authorizations and billing codes are input incorrectly or missing altogether, providers will continue to submit error-filled claims that have no hope of being paid. Tools like Patient Access Curator can verify relevant data for accuracy before claim submission and reduce the risk of denial. 2. Use AI and automation for efficiency If there was ever a case for using automation and artificial intelligence, it's in claim denial prevention. However, around half of providers are still using manual processes, leaving them playing catch-up to the payers who are already using AI to work at scale. Only 10% have automated the process, using AI to correct and resubmit claims. Tools like ClaimSource® can automate eligibility verification and coding, perform error checks before submissions and ensure claims meet payer requirements instantly. This cuts the time and effort wasted on manual processes, releasing staff to focus on activities that need human attention. 3. Automate pre-claim scrubbing to catch errors A great use case for automation is in providing an extra pair of eyes to pore over claims and catch common errors like missing data and wrong codes before submission. Experian Health's Claim Scrubber analyzes claims line by line to ensure that claims are submitted to payers and clearinghouses without errors, increase first-time pass rates and prevent rebilling. 4. Track performance for ongoing improvement Every denial prevention strategy should include monitoring and reporting. Tools that offer real-time tracking of key performance indicators such as denial rates, clean claim percentages, resubmission times, and the reasons for denials can help staff identify patterns. With these insights, they'll have complete visibility into any recurring problems clogging up their claims processes. 5. Outsource to a trusted vendor for extra support and expertise Finally, providers might consider outsourcing denial prevention to a specialist vendor who can help them develop the right strategy and toolkit to streamline billing, improve data integrity and manage claims to ease pressure on internal resources. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Proactively reducing claim denials These strategies raise an important question: can existing revenue cycle technology handle the increasing volume of denials? Healthcare administrators aren't convinced: only 54% of survey respondents feel their organization's technology is sufficient to meet demand, down 23 percentage points since 2022. To implement these denial prevention strategies effectively, providers may need to consider upgrading their toolkit rather than relying on traditional systems. Experian Health offers two AI-powered solutions that help providers better predict and prevent denials: Prevent denials with Patient Access Curator  Too many denials originate in patient access, so prevention must start here. Patient Access Curator uses AI-driven data capture technology to verify patient details quickly and accurately. With a single click, PAC can automatically check eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, coverage discovery and financial status. Running multiple manual queries is a thing of the past, saving staff hours and propagating clean data throughout the entire revenue cycle. Watch the webinar to learn more about how Patient Access Curator helps prevent denials with accurate data from the start. Predict denials with AI AdvantageTM Clean data sets the stage for denial prevention, but AI adds an extra layer of protection by forecasting potential issues before it's too late. AI AdvantageTM does this in two ways. First, the Predictive Denials component analyzes claims using the provider's own ClaimSource® data and alerts staff to high-risk claims so errors, inconsistencies or missing documentation can be corrected before submission. Next, the Denial Triage component prevents missed revenue opportunities by segmenting denials and guiding staff to those worth reworking. See how AI Advantage works: If providers can't prevent denials, they can't protect their bottom line. With the right data analytics, automation and AI, providers can take control and spot issues before they become problems instead of spinning their wheels in endless rework. With more advanced tech on their side, it's possible to close the gap with payers and prevent denials, but it also gives staff the headspace to focus on patient care and support. Find out more about how Experian Health's Claims Management solutions help providers build effective denial prevention strategies and reduce lost revenue. Learn more Contact us

According to a new report by the American Hospital Association, administrative costs now make up over 40% of total hospital expenses. Hospitals and health systems spend around $40 billion annually on billing and collections alone. For revenue cycle managers, the pressure is building as administrative tasks like insurance eligibility verification, claims management and payment processing overwhelm their teams and drain budgets. However, a sizeable chunk of these costs—perhaps as much as $18.3 billion—could remain in hospitals' hands if certain administrative tasks were automated. Automating key revenue cycle management (RCM) workflows improves efficiency, accuracy and cash flow, while easing staff stress and expediting patient care. Could it be the secret weapon to alleviating administrative burdens? This article looks at the issues in further detail, and explores 5 use cases that show how automation can reduce administrative costs in healthcare. Understanding administrative costs in healthcare Spending on healthcare administration in the U.S. has risen from $654 per person in 2013 to $925 in 2021. Administrative costs cover the resources needed to manage the non-clinical aspects of care. These resource requirements are immense in a complex system with multiple payers, fragmented data systems and growing regulatory demands. Add persistent staffing shortages and increasing patient volumes to the mix, and it's easy to see how costs spiral out of control – especially when relying on inefficient systems. The billions of dollars and hours of staff time consumed by administrative tasks make it clear that resources are not being used most effectively. This is where automation can make a difference. The role of automation in healthcare Automation reduces human errors, speeds up workflows and accelerates cash flow. It frees up time, money and headspace to optimize services and improve patient experiences. It's no wonder it's gaining traction in revenue cycle management. However, many providers are not fully capitalizing on automation's potential: Experian Health's latest State of Claims 2024 report shows that fewer healthcare administrators feel their organization's technology is sufficient to meet RCM demands compared to two years ago. How can they tap into the benefits of automation to reduce administrative costs? Benefits of automation and how it can reduce administrative costs in healthcare Automating healthcare administration is about doing more – and better – with less. Some of the benefits include: Fewer errors in billing, coding and claims management. Fewer mistakes mean fewer denials, which translates to faster payments and less rework. Reducing time to get paid, as automated processes speed up claim submissions, insurance verification and payment collections. Cash flow improves and staff spend less time chasing payments. Alleviating staffing shortages, as automation takes care of repetitive tasks like data entry, payment reminders and reporting. Management can reduce the burden on overworked staff and curb training costs, while teams can focus on “value-added” work. Improving efficiency in every corner of the revenue cycle. Automating routine tasks makes the entire billing and revenue cycle process more efficient, allowing teams to handle more work in less time without increasing headcount. Happier patients (and a better-looking bottom line). Automation makes it easier for patients to understand their bills, set up payment plans and pay their balances online. Satisfied patients are more likely to pay on time, reducing the cost of chasing overdue payments. Implementing automation in healthcare When it comes to reducing administrative costs, selecting the right parts of the workflow to automate is key. Here are five possible use cases to consider: 1. Streamline insurance eligibility checks “Checking if my insurance was accepted was a fast and friendly process. The staff even helped clarify which insurance was the right one for me since I had multiple cards.” This is what one patient at Providence Health said, after the health system switched to automated insurance eligibility verification. Insurance Eligibility Verification connects to over 900 payers and automatically checks patients' coverage and plan-specific benefits information in real-time. This reduces the manual effort required by staff and prevents the delays and denials that lead to additional administrative costs. As the patient notes, it means patients get early clarity about how their care will be funded, so there are no surprises later. Read the case study: How Providence Health found $30M in coverage and reduced denials with automated eligibility checks. 2. Automate claims submission More than half of healthcare administrators say that claims errors are increasing. A quick win would be to use automation to pre-fill patient data and avoid the inconsistencies and typos that occur with manual input. A more significant gain could come from combining multiple automations to populate, check and track claims submissions. Tools like ClaimSource® can automate the entire claims cycle in a single application. Indiana University Health (IU) utilized ClaimSource to process $632 million in claims transmissions in just one week, after a halt to their operations. Summit Medical Group paired Claim Scrubber with Enhanced Claims Status to improve claims submission. Claim Scrubber ensures all claims are complete and accurate before being sent to the payer, and generates alerts so staff can intervene quickly if an error pops up. Enhanced Claim Status automatically pings payers for status requests so staff can spend less time seeking updates and accelerate follow-up activities. With this approach, Summit boosted their first-time pass-through rate to 92% and reduced accounts receivable days by 15%. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more 3. Improve denial management Denials remain one of the biggest pain points for providers. Payers are miles ahead in their use of automation and artificial intelligence (AI), using sophisticated machine learning tools to process and deny claims at scale. Experian Health's flagship AI-powered denial management solution, AI AdvantageTM, can help close the gap. This tool “learns” from an organization's historical claims data and trends in payer behavior to predict the probability of denial. It also identifies and segments denials so staff can prioritize those with the highest chance of being reimbursed, reducing the time and cost of manual appeals and rework. 4. Accelerate patient payments On the patient side, automation can be deployed to send patients reminders about outstanding balances, set up payment plans and process payments quickly and securely. Simplifying patient billing makes it easier for patients to pay, which increases collections rates while reducing the need for follow-up calls. Read more: 5 ways patient payment software improves patient satisfaction 5. Generate better financial reports Another smart use case for automation is generating real-time revenue cycle performance reports. With advanced data and analytics, staff no longer need to spend hours compiling information, while managers get faster, reliable information to inform strategic decisions. Experian Health's healthcare data analytics turns raw data into business-ready information to find potential sources of revenue leakage and boost financial performance. The future of healthcare automation Automation is already helping reduce administrative costs in healthcare by relieving staff of the tedious, time-consuming, repetitive tasks that drain time and money. However, many still rely on old data systems that don't work well together, leaving revenue opportunities slipping between the cracks. Choosing solutions that improve integration and interoperability will continue improving data-sharing between platforms and services, further reducing errors and delays. Looking ahead, automation and AI will play an increasingly major role in handling complex tasks in revenue cycle management. RCM leaders will find even more opportunities to minimize manual intervention and lower administrative overheads as these tools evolve. Learn more about how Experian Health's automated Revenue Cycle Management solutions help reduce administrative costs in healthcare and create more resilient revenue cycles. Learn more Contact us

Could healthcare organizations be doing more to open their digital front door? According to a 2024 study by HIMSS researchers, hospitals that embrace digital technology see stronger patient experience outcomes. This aligns with Experian Health's most recent State of Patient Access (SOPA) survey, in which patients and providers agreed that patient access had improved thanks to digital technology. Adoption of digital health technology accelerated in response to COVID-19, as healthcare organizations sought to manage demand and facilitate “contactless” access to care. Telehealth, mobile apps and patient portals gave patients more control over their health while allowing providers to deliver more personalized and efficient care. With over half of healthcare providers and nearly a third of patients acknowledging improvements in access since before the pandemic, it's clear that offering more digital options is a powerful strategy to improve patient engagement and streamline access. Progress is encouraging, but there are always opportunities to do more. What is healthcare's digital front door? Healthcare's “digital front door” includes all the digital channels through which patients access care, such as websites, patient portals, mobile registration and payment apps, telehealth platforms and online scheduling tools. The goals are to create convenient and user-friendly entry points for patients to engage with their providers, use online tools to expand access, improve patient satisfaction, and increase operational efficiency. Why a digital front door is crucial for healthcare providers When asked why they believe patient access has improved since before the pandemic, the top four reasons given by patients all relate to scheduling and registration processes: Being able to see a doctor quickly (72% agreed) Checking in and registration (61% agreed) Scheduling appointments (58% agreed) Finding appointments that work with their schedule (57% agreed). In other words, patient access improves when providers open the digital front door. Alex Harwitz, VP, Digital Front Door, at Experian Health, explains that for providers, this equates to two major benefits: 1. Improves patient engagement Harwitz says that putting access in the hands of patients gives patients more flexibility and choice about how and when they book appointments, fill out registration forms and pay for care. “There's a growing demand for easy, accessible healthcare, and opening the digital front door is how we meet it. Digital tools use automation and data analytics to create a more personalized and convenient patient experience, making it easier for patients to remember appointments, adhere to treatment plans and manage their financial obligations,” he says. “That's huge for busy households. The to-do list just got a lot shorter, so it's easier for them to engage.” 2. Streamlines patient access A second key benefit is reducing friction and bloat in patient access workflows. Harwitz says, “By expanding their online offerings, providers not only make it easier for patients to see their doctor sooner, but they also reduce demand on front office staff. Self-service options, performance reporting and data insights allow providers to allocate resources more effectively. It’s about making sure everyone gets the right support at the right time, whether that's online or in the office.” Getting the patient journey off on a strong footing also pays dividends throughout the rest of the revenue cycle: with fewer errors and faster throughput, collections and claims management improve, too. Read more: How patient access technology is transforming the healthcare revenue cycle Key components of a digital front door As more providers offer online patient access, competition for the digital front door is increasing. With 60% of patients looking for more digital and mobile options to meet with providers, schedule appointments, and manage bills and payments, these would be smart areas to prioritize for a competitive advantage. Here's what that might look like: 1. Cut paperwork and calls with self-service scheduling and mobile registration It should come as no surprise that a vast majority of patients say they do not like repetitive paperwork. Online and mobile-enabled scheduling and registration reduce form-filling and lengthy calls. For example, Patient Schedule gives patients a platform to book, cancel and reschedule appointments with ease, anytime and anywhere. Appointments are matched to patients' needs so no slots are wasted and patients see their doctor sooner. Mobile registration increases bookings further. With Registration Accelerator, patients receive a text that prompts them to scan their identity and insurance cards, so they don't need to wait in line to fill out forms. Validating their data from the start also improves billing accuracy and reduces the risk of downstream denials. 2. Make it easier to pay for care Simplifying the financial experience is a major component in opening the digital front door. Patients are worried about the cost of care and say that having accurate price estimates before treatment helps them plan for bills. With Patient Payment Estimates, providers can give patients accurate, upfront estimates of their out-of-pocket costs, while tools like Patient Financial Clearance can help direct them to appropriate payment plans. It's also important to make the actual payment process as straightforward as possible. Accepting payments 24/7 from any device allows patients to pay promptly and helps providers avoid bad debt. Checklist: 5 patient-friendly billing practices to accelerate collections 3. Communicate clearly for a great first impression At its core, opening the digital front door is about creating a welcoming first impression for patients. Patients don't want confusing instructions or radio silence when they have questions. They want proactive, helpful and clear communications. One of the benefits of digital tools is having the data and automation capabilities to send patients timely and personalized messages and reminders using their preferred channels. They can also drive targeted outreach campaigns using text messages and interactive voice responses to encourage patients to book appointments and make payments. The future of healthcare's digital front door These are just a few examples of how providers can expand their digital offerings to make it easier for patients to access care. But what will the digital welcome mat look like in the future? Advances in artificial intelligence, digital apps and wearable tech will transform the way patients interact with their providers. Hockey-stick growth in data generation will make data security and interoperability non-negotiable. It's a big ask of providers. Partnering with an expert third-party vendor will help digitally forward organizations remain responsive and adaptable. Find out more about how Experian Health helps providers open their digital front door with mobile scheduling, registration and payments.

Maintaining a healthy cash flow is the only way to deliver quality patient care, invest in state-of-the-art technologies and keep daily operations running smoothly. But that's easier said than done: data errors, delayed payments, denials and staffing disruptions leave providers vulnerable to escalating admin costs and revenue leakage, with little left over to reinvest. By adopting a few key revenue cycle management (RCM) strategies, providers can sidestep these challenges and bring in more dollars. This guide summarizes five revenue cycle management best practices healthcare leaders should follow to optimize RCM workflows and promote financial stability. Key challenges in revenue cycle management Common issues that can get in the way of a healthy revenue flow include: Inaccurate patient data leading to coding errors, claim denials and billing delays Increasing numbers of denied claims generate costly rework and wasted time Payer compliance issues that are constantly changing and time-consuming to monitor Growing numbers of self-pay patients struggling to pay their bills Labor shortages increase pressure on staff and leave the door open to sub-par performance Inadequate data insights hindering management's ability to spot opportunities for improvement Rapid technological changes leave providers on the back foot if they fail to keep pace with new developments. The dream scenario would be to avoid all these potential obstacles before they do too much damage. In reality, providers will need to choose a few priority areas to troubleshoot. Check out this guide to choosing the right key performance indicators for your revenue cycle dashboard to ensure the effective implementation of RCM strategies. Revenue cycle management best practices What does a successful revenue cycle look like? For busy RCM leaders, deciding what to tackle first can be overwhelming. While there's no one-size-fits-all RCM strategy, there are a few key issues that all organizations must pay attention to. Here are five areas of best practice to factor in: 1. Streamline patient registration and insurance verification Accurate patient data is the number one factor in building a robust revenue cycle. It doesn't matter how efficient claims management and collections processes are if the data they use is flawed. Automated registration and verification tools reduce the chances of manual errors entering the system to ensure correct billing, reduce denials, and speed up reimbursement. One pitfall to watch out for is the fact that some digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility. Experian Health's latest patient access solution, Patient Access Curator, avoids this by using AI-driven technology to collect and verify patient information with a single click. 2. Automate claims submission and management According to Experian Health's State of Claims 2022 report, 62% of providers feel they lack the necessary data and analytics to identify issues in claims submission processes. A similar number believe the absence of automation prevents improvement. The CAQH Index backs this up, with the latest estimates suggesting the healthcare industry could save $18.3 billion by switching to electronic transactions. As with patient intake, there's an opportunity to leverage automation in claims management to prevent errors and delays so the organization gets paid faster. Experian Health's claims management products—ranked #1 in 2024 surveys by both KLAS and Black Book—automate each step of the claims workflow so providers can submit clean claims quickly and cut the need for time-consuming manual work. 3. Optimize denials management and appeals with AI Despite best efforts, claims denials remain a burden for many RCM teams. However, proactively understanding and addressing the root causes can help keep denials under control. There's an opportunity to go a step beyond automation and see how artificial intelligence and machine learning can help combat the denials challenge. AI AdvantageTM evaluates individual claims in real time to flag those with a high likelihood of denials based on historical payment data, so staff can intervene quickly before submission. Denials are then triaged using advanced algorithms so staff can focus on reworking denials with the greatest chance of payment, rather than wasting time on those that are never going to be approved. Eric Eckhart, Director of Patient Financial Services at Community Medical Centers in California, says that since implementing AI Advantage, “Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in-house and save money. The savings have snowballed. That's really been the biggest financial impact.” Watch the webinar: Hear how Community Medical Centers and Schneck Medical Center are using AI AdvantageTM to prevent and triage denials. 4. Choose the right technology and tools for enhanced RCM The three previous revenue cycle management best practices emphasize the importance of selecting the right tools for the task. Two things to look out for when adopting a new RCM product are how well it integrates with existing tools and systems, and whether it offers meaningful insights to drive ongoing improvements. Experian Health's integrated RCM solutions are designed to fit together seamlessly, often allowing staff to view information from multiple workflows within the same dashboard. By bringing together metrics such as financial performance, billing efficiency and collections rates into one place, these tools help staff make strategic decisions about resource allocation and operational improvements. 5. Keep up with regulatory compliance Finally, ensuring compliance with regulatory requirements cannot be overlooked. The reputational and financial risks are too great. Regular training for staff on compliance issues and maintaining up-to-date knowledge of government and payer requirements will minimize the risk of penalties. Choosing RCM tools that automatically check for relevant updates can help providers stay current. Price transparency is a topical example. While the Hospital Price Transparency Rule is designed to help healthcare consumers understand healthcare costs and make more informed decisions about their care, implementation has proven tricky for providers. With the right technology and third-party support, it's much easier to stay compliant. Watch the webinar: See how Experian Health and Cleverley & Associates have partnered to help healthcare organizations navigate price transparency in 2024. Looking for more insights into revenue cycle management best practices? Contact Experian Health today to discover how our RCM solutions can transform your revenue cycle and increase cash flow year over year. Revenue cycle management solutions Contact us

In healthcare revenue cycle management (RCM), the mantra is clear: maximize revenue and minimize costs. It's more complex in practice, requiring RCM leaders to anticipate and adapt to whatever's around the corner. Following the latest revenue cycle management trends is vital, as economic turbulence and labor shortages demand flexibility and resilience. Competition from new players and changing consumer expectations call for constant updates to the latest technology. And currently, as electoral news cycles heat up ahead of the general election, attention is turning to potential policy changes and their implications for revenue cycle management. Keeping an eye on how the industry evolves will help RCM managers hold the course for financial stability and growth. Here are 12 revenue cycle management trends to watch: 1. Investment in managed RCM services Investment in managed RCM services has become an increasingly attractive option for RCM managers grappling with persistent workforce challenges and navigating the intricate landscape of payer policies. Outsourcing has become a strategic solution to address staffing shortages and limited resources. By partnering with vendors like Experian Health, healthcare organizations can get access to specialist expertise, datasets and automated technologies they'd be hard-pressed to develop in-house. For example, Collections Optimization Manager allows users to retain control and oversight of their collections processes but comes with real-time support from a dedicated Collections Optimization Consultant for a bespoke collections strategy built on data insights and industry knowledge. 2. Staff shortages and reimbursement model changes Staffing shortages are particularly problematic when they bump up against changing reimbursement models. Unfortunately, staffing shortages are still common in the future of revenue cycle management. In Experian Health's latest staffing survey, 69% of respondents believe that staffing will continue to be a problem in the future. More providers are moving to value-based care models, which have implications for claims submission processes and provider-payer relationships. High staff turnover leaves providers without the knowledge and expertise to handle more complex claims and billing processes. A tool like Contract Manager and Contract Analysis, recently awarded Best in KLAS for Contract Management, helps monitor and manage payer contracts to stay on top of terms and conditions, mitigate risk and maintain financial stability. 3. Workflow inefficiencies Another way to ease staffing pressures is to improve workflow efficiency. A recent Bain report found that 40% of clinicians reported a lack of effective workflows, while up to 70% had never tried automated workflow management. There's a missed opportunity here, as manual processes and communication bottlenecks seriously disrupt revenue cycle functions. Organizations that leverage more efficient ways of working will secure a competitive advantage as new demands and pressures arise. Reviewing key performance indicators is a good starting point for determining where to focus improvement efforts. 4. Technological advancements in RCM The ongoing evolution of artificial intelligence (AI) has profoundly impacted various sectors, and the realm of revenue cycle management is no exception. AI-based tools will continue to shape the future of revenue cycle management, and providers will have to implement these tools in order to keep up with the competition. Machine learning algorithms increase RCM efficiency and accuracy by automating routine tasks, while advanced tools like AI AdvantageTM analyze vast datasets to identify patterns and predict outcomes. AI Advantage transforms claims management by predicting claims that are most likely to be denied, and then triaging denials so staff can focus on those with the highest likelihood of reimbursement. Eric Eckhart, Director of Patient Financial Services at Community Medical Centers, says, “We were looking for something technology-based to help us reduce denials and stay ahead of staff expenses. We're very happy with the results we're seeing with AI Advantage.” 5. Technology integration The amount of data being collected, generated, processed and shared within healthcare organizations is skyrocketing. More data means greater capacity for personalized services, fewer gaps in care, and more streamlined RCM processes—but only if data systems talk to one another. Opting for a single integrated solution avoids the pitfalls of shoe-horning new tools into legacy systems. For example, Experian Health's acquisition of Wave HDC means organizations can now access a single tool to check multiple data sources at registration. Patient Access Curator uses AI to perform eligibility verification, coordination of benefits, coverage discovery and more, to help healthcare organizations accelerate registration and reduce claim denials. 6. Medical billing errors Whether a coding mistake or an accidental typo, billing errors cost providers dearly in lost revenue and time. Unfortunately, they're a growing risk as more patients show up with coverage from multiple payers and high deductibles. On the upside, organizations should see improvements with relatively little effort—assuming they deploy the right tools and strategies. Patient Access Curator, mentioned above, uses AI and robotic process automation to collect and verify the information needed to compile error-free claims with just a single click. Watch the webinar to find out more about how Patient Access Curator helps providers eliminate errors and reduce claim denials from the front end. 7. Patient-centric approaches A McKinsey report published in April 2024 highlighted a continuing trend in healthcare consumers' keenness to use digital products and services when accessing care. Experian Health's series of patient access surveys show a consistent desire for personalization, convenience, choice and compassion in patient access. These principles underpin Experian Health's approach to helping providers open their digital front door. Online self-scheduling, digital registration, and tailored patient outreach all improve patient satisfaction and engagement, subsequently bolstering revenue generation. 8. Financial clearance and diverse payment options One specific opportunity relating to the above point lies in offering a patient-centered financial experience. Financial clearance tools and flexible payment plans have gained prominence by making it easier for patients to understand and manage their financial obligations. Tools like Patient Financial Clearance automate presumptive charity screening to see if patients qualify for financial assistance programs, provide scripts to help staff deliver compassionate financial counseling, and calculate affordable monthly payments based on individual circumstances. Case study: Discover How UCHealth wrote off $26 million in charity care with Patient Financial Clearance. 9. Financial engagement and omnichannel platforms Patient collections are a growing challenge for providers. Patients similarly complain of unnecessary friction in the payment process: The State of Patient Access 2024 survey found that 72% of patients want more digital payment options digital methods. By providing a unified experience across online portals, mobile apps and point-of-service payments, providers can increase patient engagement with financial processes and accelerate collections. 10. Challenges specific to each revenue cycle segment Organizations are shifting away from uniform solutions for the entire revenue cycle and instead embracing tailored strategies that accommodate the unique requirements of various departments, services, and workflows. By harnessing advanced analytics and automation, providers gain insight into the nuanced challenges within revenue cycle management, enabling them to adopt the best tools. This approach ranges from customizing intake and billing processes on a departmental basis to automating claims processing tailored to different payers' specifications. 11. Customizable RCM solutions Just as patients want tailored solutions, so too do providers. Data analytics and AI advancements enable providers to develop claims management solutions that fit their unique mix of payers and patients. On a recent webinar, representatives of Eskenazi Health discussed their use of Patient Financial Advisor, and how Experian Health consultants helped their organization customize their setup and workflow. 12. The role of strategic partnerships Partnering with a vendor like Experian Health can be a transformative step for healthcare organizations seeking to optimize their operations and enhance patient care. With Experian Health's expertise in healthcare technology and data management, organizations gain access to a comprehensive suite of automated solutions tailored to their specific needs. This also ties in with the first item in this list: implementing new ways of working isn't always easy, but with a trusted vendor, providers can manage and accommodate revenue cycle management trends more confidently, efficiently, and cost-effectively. By partnering with Experian Health: Providence Health found $30million in coverage and reduced denial rates IU Health processed $632 million in claims transmissions The pace of change may be relentless, but with the right tools and support, RCM managers can stay one strategic step ahead and future-proof their revenue cycle for whatever surprises lie in store. Learn more about how Experian Health's revenue cycle management solutions can help providers keep up with revenue cycle management trends while maximizing revenue and minimizing costs.

As revenue cycle leaders continue to navigate an increasingly complex financial landscape, preventing healthcare claim denials remains the number one priority. Experian Health's State of Claims 2022 report found that 30% of respondents see claims denied 10-15% of the time, while 42% were seeing the rate of denials increase year over year. Denials in healthcare, which can be easily avoided, contribute significantly to the waste of healthcare funds. These denials cause providers to lose hundreds of billions of dollars in profits annually. This blog looks at the key questions providers should ask to get to the bottom of why healthcare claims get denied, how to prevent healthcare claim denials and ways technology can support better denial management. Why do healthcare claims get denied? The State of Claims 2022 survey revealed that the most common causes of denied claims boil down to three issues: 1. Missing or incomplete prior authorizations Health insurers use prior authorizations to determine whether a patient's treatment is medically necessary and how much they can cover. Despite being introduced to encourage delivering high-quality, cost-effective care, the authorization process has become an intimidating administrative burden for healthcare providers. Even now, many healthcare providers rely on manual paperwork to execute an already complex and tedious authorization process. This outdated approach to authorization not only consumes time and money but also creates opportunities for missing or incomplete prior authorizations, increasing claims denial rates. Unsurprisingly, 48% identified missing or incomplete prior authorizations as one of the top three reasons for denials. 2. Failure to verify provider eligibility To be eligible for reimbursement, a provider must be a participant in the proposed Medicare or Medicaid program or other private health insurance plan. Eligibility verification involves confirming a patient's insurance information and that the planned services and provider are under their plan, which is critical for successful claims approval. Failure to verify provider eligibility may lead to claims denial if an out-of-network provider provides the services. Likewise, 42% of respondents said failure to verify provider eligibility was a common reason for denials. 3. Inaccurate medical coding Accuracy is the backbone of medical coding, another administrative task indispensable to claims approval. The slightest mistake when translating patients' diagnostic and treatment information into clinical codes can result in rejected claims. Unfortunately, providers are susceptible to coding errors due to the ever-changing coding rules, especially when they do it manually or work with unreliable automation solutions. They may work with outdated or incorrect codes, leading to claims denials. The State of Claims 2022 survey revealed similar shortcomings, with 42% of respondents stating that inaccurate medical coding led to denial. Other reasons for denied claims include: Incorrect modifiers Failure to meet submission deadlines Patient information inaccuracy Missing or inaccurate claim data Not enough staff to keep up Formulary changes Changing policies Procedure changes Improperly bundled services Service not covered 6 in 10 respondents said insufficient data and analytics made identifying and resolving issues with claims submissions difficult. A similar number said a lack of automation was hindering operational improvements. The good news is that these obstacles can all be effectively addressed with the right denial management strategy and digital tools. How do claim denials affect revenue cycles? Denials can be justified as necessary to prioritize spending on high-value care, but they have heavy consequences for hospitals' financial health. As highlighted in the Journal of Managed Care & Specialty Pharmacy, the weight of denied claims adds up to about $260 billion each year. This financial burden is pushed on hospitals, who may need to classify denied claims as debt, which, among other consequences of claims denial, ultimately disrupts their revenue cycles. The ripple effect of denied and underpaid claims on hospital revenue cycles also manifests in how delayed and non-payments restrict cash flow, hampering the provider's ability to operate efficiently and deliver care effectively. Significant staff time is lost to avoidable administrative activities and rework, as claims need to be corrected and resubmitted. This creates a bottleneck in the revenue cycle, which can lead to decreased revenue and additional costs. Extra work is particularly challenging for staff already under pressure due to ongoing labor shortages. For patients, denials can cause stress and confusion around how the cost of care will be met. How can providers reduce or prevent healthcare claim denials? Since most denials result from inaccuracies that originate early in the patient journey, the solution calls for better data management in patient access and robust checks just before claims are submitted. Reducing claims errors will contribute to better claim submission and higher reimbursement rates. Here's a step-by-step guide to improving healthcare claims processing: Utilize prior authorization software to automate the prior authorization process. This software-driven solution automates inquiries and submissions using updated and stored payer data, making the prior authorization process seamless and time-efficient and resulting in higher claim approval rates. Upgrade claims technology with tools such as ClaimSource®, which helps providers manage the entire claims cycle from one platform. By automating claims processing, ClaimSource helps ensure claims are clean before being submitted. The tool creates custom work queues so staff can prioritize high-value tasks and get paid faster. Improve the claims management process and prevent healthcare claim denials with AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. Predictive Denials flags claims that are more likely to be denied before they are submitted to the payer and tracks payer rule changes, reducing denial rates. Denial Triage prioritizes and segments denials most likely to be reimbursed, leading to increased revenue. Automate line-by-line claim reviews with Claim Scrubber to eliminate errors or omissions in claims before they are submitted. Claim Scrubber makes claims management operations more efficient, resulting in less rework, administrative costs, and delays. It can also be paired with Contract Manager, so providers can audit claims before and after remittance. Use an early-and-often approach to monitoring claim status and expedite reimbursement. Enhanced Claim Status eliminates manual follow-up and helps providers react quickly to any pending, returned-to-provider, denied, or zero-pay transactions, further improving cash flow. Experian Health's ClaimSource and Contract Manager solutions were both ranked number one in their respective categories in the 2024 Best in KLAS awards What is the best way to track and manage claim denials?  Most providers rely on manual and automated processes to manage claims and denials. Shifting from manual to digital can save time, reduce errors, and increase overall efficiency. However, providers may be wary of implementing new systems due to concerns about costs, data interoperability, and the staff learning curve. For this reason, it's essential to select a denials management solution that fits the provider's unique specifications. Denials Workflow Manager eliminates manual processes and allows providers to optimize the claims process according to the metrics that matter to them. It generates work lists based on the client's specifications, such as denial category and dollar amount, and incorporates extensive data analysis capabilities to identify the root causes of denials and improve upstream processes to prevent them. It can be easily implemented as a standalone product or integrated with ClaimSource to give users access to the entire claims and denial management cycle on a single screen. Staff training on claims management The State of Claims 2022 report revealed that 46% of respondents admitted that lack of staff training was an operational challenge contributing to claims denial. Training healthcare staff in managing and preventing claim denials is one of the most worthy investments to reduce the rate of claim denials. Hospitals can provide healthcare staff with adequate ongoing training on the granular details of claims processes before and after submission and access to automated claims management solutions. Healthcare staff should also be kept up-to-date on the latest tools and strategies on denial prevention and payer rules for claims submissions to ensure payment receipt after claim submission. Engaging patients in the claims process Though patients are usually not responsible for submitting claims to payers, they are an equal third party in the claims process and can be empowered to actively participate in every stage, from submission to approval and paying copays or deductibles. Effective patient engagement can be achieved by providing patients with an accessible, all-inclusive platform to register, review, and update information related to their care and benefit plan and communicate with healthcare staff as needed. Collaborating with payers to reduce denials The quality of collaboration between payers and providers affects the seamlessness and efficiency of the claims process. Therefore, it is crucial for providers to collaborate effectively with payers, especially given the constant changes in payer policies, to ensure that they stay up-to-date with and comply with the payer claims submission requirements. In cases of claim denials, they can also manage them effectively. By working together, payers and providers can also quickly resolve denial issues, ultimately improving system efficiency. Adopting automation and AI to prevent healthcare claim denials As one of the most complex institutions today, the healthcare industry has always grappled with a critical shortage of healthcare workers, staff burnout, and wasteful medical care spending, which costs $600 billion annually in the US. Despite the potential benefits of automation and artificial intelligence (AI) to ease these burdens and save about $200 billion to $360 billion annually in healthcare spending, their adoption has been lagging and met with resistance. However, more and more healthcare stakeholders are realizing that these technologies are a principal partner in making the healthcare system more efficient, simplifying and streamlining deeply complex processes, such as claims processing. For example, Experian Health's Patient Access Curator, an AI—and robotic process automation (RPA)-driven solution that enables eligibility and coverage verification and more accurate and submission-ready claims. By performing these tasks in seconds, all in one click, Patient Access Curator has helped clients save over $1 billion in denied claims since 2020, significantly boosting their bottom lines. Another example of efficient claims technology is ClaimSource. This all-in-one claim cycle management platform, powered by automation, transmitted $632 million in claims within five days and processed $1.1 billion of claims backlog for IU Health. AI Advantage™, Experian Health's revolutionary claims management solution that offers a two-pronged approach to preventing and managing denials: 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. Given the volume, complexity and financial impact of the current claims workload, automation and AI are critical elements in the denials management toolkit. In the State of Claims survey, more than half of respondents said they were using automated claims processing, with many using automation to keep track of payer policy changes, automate patient portal claims reviews and digitize patient registration. Despite much media furor, AI is still the domain of early adopters: only 11% of respondents said they were using AI. But while automation can effectively eliminate unnecessary manual tasks, AI is a force multiplier for denials management, offering additional predictive capabilities and “learning” from historical data to prevent denials. Client feedback to date suggests that incorporating AI-powered denial management solutions could be a game-changer for providers looking to streamline operations, prevent lost revenue and free up capacity to focus on their primary mission of delivering quality patient care. Technology solutions for managing and preventing claim denials Efficiently managing the claims process and preventing or resolving claims denial requires robust and reliable technology solutions at every stage, especially in the complex and constantly changing world of claims management, where everything hinges on accuracy. These technology solutions can be responsible for heavy lifting many administrative tasks involved in the claims processes, from accurate data capturing during patient registration and prior authorization to submission to monitoring claim status and addressing claims submission outcomes. Hospitals can adopt claims technology, such as Experian Health's Patient Access Curator, for verifying insurance eligibility and coverage with real-time patient data correction or ClaimSource®, a single platform for monitoring and managing the claims cycle in one place. Find out more about how Experian Health helps healthcare providers prevent healthcare claim denials with automation and AI.

With millions of healthcare claims to process and millions of dollars at stake each month, getting claims right the first time is a top performance indicator for healthcare providers. The administrative burden is immense – there are more than a thousand health payers, each with their own requirements, edits and software. Each claim must be scrubbed to make sure every last detail is correct before it's submitted – or the result will be delayed payments and lost revenue. By taking this resource-intensive activity off providers' hands, medical billing clearinghouses are often the “most valuable player” of healthcare claims management. Choosing the right medical claims clearinghouse could make or break a provider's claims management success. What is a medical claims clearinghouse? Healthcare clearinghouses help providers increase reimbursement rates by checking each claim before it's submitted to the payer. They scrub for errors and omissions, then reformat the data to meet the specific requirements of each payer. Once a claim is cleared, the clearinghouse transmits the electronic claim (the “837 file”) to the appropriate commercial or government payer using a secure connection, in line with the Health Insurance Portability and Accountability Act (HIPAA). The payer evaluates the claim and communicates acceptance or rejection to the clearinghouse. If payment is due, the payer will issue a reimbursement check with an Explanation of Benefits (EOB) statement. Rejected claims may be resubmitted once any corrections have been made. This sounds like a simple process, but it's extremely complex. Tracking and adapting to individual payer edits, state insurance regulations, and multiple software systems call for a level of expertise and industry insight that would be challenging for in-house teams to maintain efficiently. With a singular focus on claims routing and the quirks of individual payer adjudication workflows, healthcare clearinghouses are often better placed to streamline electronic claims submissions. What services do clearinghouses help with? A healthcare clearinghouse can typically offer: Claims processing: Managing the submission, processing, and tracking of medical claims electronically to insurance payers. Denial management: Handling denied claims by identifying the reasons for denial, correcting errors, and resubmitting claims for reimbursement. Real-time eligibility verification: Verifying patients' insurance coverage and eligibility in real time to ensure accurate billing and reduce claim denials. Electronic data interchange (EDI): Facilitating the electronic exchange of healthcare data between healthcare providers and insurance payers in standardized formats. Electronic remittance advice (ERA) processing: Receiving and processing electronic remittance advice from insurance payers to reconcile payments and denials with submitted claims. Claim scrubbing: Checking claims for errors, inaccuracies, and missing information before submission to reduce the likelihood of claim denials. Coordination of benefits (COB) verification: Identifying primary and secondary insurance coverage for patients with multiple insurance plans to ensure accurate billing and reimbursement. Claim status inquiry and reporting: Providing tools and services to track the status of submitted claims and generate reports on claim processing metrics. Compliance and regulatory support: Ensuring compliance with healthcare regulations, such as HIPAA, and staying updated on changes in billing requirements and coding standards. Provider enrollment: Helping healthcare providers enroll with insurance payers and update their provider information as needed. Appeals management: Assisting healthcare providers in appealing denied claims through proper documentation and communication with insurance payers. EDI connectivity and integration: Offering connectivity solutions and integration services to seamlessly exchange data between healthcare providers' practice management systems and the clearinghouse platform. Customer support and training: Providing ongoing support and training to healthcare providers and their staff on using the clearinghouse platform effectively and resolving issues related to claims processing and reimbursement Why work with a medical claims clearinghouse? The answer lies in the growing problem of denied claims. Denials dent provider profits through lost revenue and time wasted on reworking claims. A 2021 KFF study of in-network claims found that 18% were denied because they were for excluded services, 9% because of missing prior authorization or referrals, and 72% because of “other reasons.” This likely includes incorrect patient encounter codes, incomplete patient or physician information, or other data entry errors. Too many denials arise from avoidable human error. Providers can ill-afford an inefficient claims management workflow. Direct submissions require staff to repeat the same data entry tasks repeatedly, using multiple software accounts. Monitoring claims status without a centralized system is messy. And with ongoing staffing pressures, many providers don't have the resources or infrastructure to attempt this anyway. The savings of a direct-to-payer approach are soon outweighed by higher denial rates. Healthcare clearinghouses can ease the burden on in-house RCM teams, smooth friction between providers and payers, and provide industry intelligence to streamline claims submissions. By partnering with a medical claims clearinghouse, providers don't just save time and staff resources, but increase the likelihood of claims being submitted right the first time. The importance of choosing a clearinghouse that stays compliant Complying with industry regulations helps healthcare providers avoid costly fines and reputational damage. Compliance rules ensure adherence to stringent regulations like HIPAA, which safeguards patient data privacy and confidentiality, ensuring that all data handling practices comply with the highest standards. A compliant clearinghouse implements robust security measures like encryption and access controls to protect sensitive information during EDI. Staying compliant fosters trust among stakeholders, including patients, healthcare providers, and insurance payers. It demonstrates a commitment to ethical practices and upholds industry standards, promoting long-term relationships and sustainability in the always-evolving healthcare field. What to look for when choosing a medical billing clearinghouse? Here are five features to look out for when choosing the right medical billing clearinghouse partner: 1. Usability “Is this medical claims clearinghouse going to be easy to work with? Do they have a user-friendly interface?” Given that a significant motivation behind working with a medical claims clearinghouse is to make the claims process easier, the first question to ask is how easy they'll be to work with. The ideal clearinghouse partner will offer a streamlined user experience with an intuitive online claims dashboard or interface so that all claims can be managed in one place. Inevitably, issues that need to be checked by the provider's medical billing team will crop up. The clearinghouse should offer clear communication channels and protocols for verifying, correcting, and adding any missing information or documentation. Ideally, the clearinghouse's interface will provide at-a-glance error reports and updates on the status of each claim, to minimize delays and allow staff to report on progress. The clearinghouse should also offer staff training and real-time support for fast and effective implementation. Medical billing teams don't want to spend hours chasing up queries, so investigating call center support protocols and response times is a smart move. Some of the standard add-on services that make the medical claims clearinghouse more user-friendly include: Training materials: The clearinghouse should offer comprehensive training sessions, to empower healthcare providers and staff with the knowledge and skills to utilize the platform effectively. Customer service: The clearinghouse should pride itself on delivering exceptional customer service tailored to its users' unique needs and challenges. A dedicated support team is available via phone and email to promptly address inquiries, troubleshoot issues, and provide personalized assistance. Their responsive and knowledgeable approach ensures that users receive timely support and guidance whenever they require assistance. Also, look for a medical claims clearinghouse with security and privacy features to keep patient data safe. For example: Data encryption: All data transmitted through the clearinghouse platform should be encrypted using industry-standard protocols, safeguarding sensitive information from unauthorized access during transmission Access controls: Role-based access controls limit user access to specific features and functionalities based on their role and responsibilities within the healthcare organization, reducing the risk of unauthorized data access and misuse. Audit trails: Comprehensive audit trails track and record all user activities within the platform, enabling administrators to monitor and review user actions for compliance and security purposes. The medical claims clearinghouse should conduct periodic security audits and assessments to identify and address potential vulnerabilities and ensure ongoing compliance with industry regulations and best practices. Data redundancy and disaster recovery: Robust data redundancy measures and disaster recovery plans are in place to protect against data loss or corruption, ensuring continuity of service and minimizing downtime in the event of unforeseen incidents or emergencies. Confidentiality agreements: All staff members undergo training on data privacy and security practices and sign confidentiality agreements, reinforcing their commitment to protecting the confidentiality and privacy of patient information. 2. Reach and scope “Does this medical claims clearinghouse connect to all our regular payers? Will we need to engage additional clearinghouses for specific cases?” To leverage the advantages of outsourcing claims processing, providers must check that the clearinghouse can handle their specific claims mix and list their most-billed payers. Healthcare clearinghouses often specialize in different types of claims, such as in-patient, out-patient, dental, pharmacy, and so on, so this will likely be a quick way to narrow down the options. Similarly, some operate only in certain regions, and if the provider needs to submit claims to payers outside that area, they're going to need another clearinghouse. In most cases, choosing a clearinghouse with a broad reach and national scope will be beneficial so that all claims can be handled by a single vendor. If the provider plans to use the clearinghouse for Medicaid submissions, they'll also want to check that their partner is set up to do this in line with state requirements. Providers should also consider what services they need from their clearinghouse: submitting electronic claims? Verifying patient eligibility and coverage? Checking the status of claims and receiving ERAs? Some clearinghouses will perform all these functions, while others focus on one or two areas. 3. Error rates “What are the clearinghouse's average rejection rates? How can we accelerate corrections?” Minimizing billing errors is the key to reducing rejections and denials. When discussing program components with a potential clearinghouse partner, providers should look for features that minimize errors, such as checks for duplicate information, missing attachments and coding discrepancies. A dashboard that flags any potential issues means errors can be found and fixed immediately, rather than being discovered weeks later. To complement this process, providers should also consider what in-house actions could further reduce the risk of errors. Running internal checks with automated tools such as Claim Scrubber can ensure claims are in good shape before they're sent to the clearinghouse. Claim Scrubber reviews every line of pre-billed claims and verifies patient information coding entries before being sent on. General and payer-specific edits can be checked to increase first-time pass rates. Automated Prior Authorizations and Insurance Eligibility Verification tools offer another layer of extra checks, by verifying eligibility at each stage of the patient's healthcare journey. 4. Affordability “How are the clearinghouse's contracts structured? Are there extra fees to watch out for?” Providers will want to find a reasonably priced clearinghouse. Some charge a fixed monthly fee, while others charge a variable fee based on the volume of claims each month. Providers with relatively low claims should choose the first option. Eligibility checks, claim status updates and remittance receipts are likely to be charged separately, so these should also be factored into contract discussions. Because the rules around claims submissions often change, providers should avoid being locked into long-term contracts, and clarify the termination arrangements. Using a medical claims clearinghouse offers several financial benefits for healthcare providers: Faster reimbursement: Clearinghouses streamline the claims submission process, reducing the time it takes to submit and process claims. This results in quicker reimbursement from insurance payers, improving cash flow for healthcare organizations. Reduced claim denials: Healthcare clearinghouses employ claim scrubbing technology to identify and correct errors before submission, reducing the likelihood of claim denials. These solutions help minimize the need for costly appeals and resubmissions, saving time and resources. Improved efficiency: Automating manual tasks and providing electronic solutions for claims processing lets clearinghouses increase operational efficiency within healthcare organizations. Staff can focus on patient care instead of administrative tasks, optimizing productivity and reducing labor costs. Lowered administrative costs: Clearinghouses offer a centralized platform for managing claims and interacting with insurance payers, streamlining administrative processes and reducing administrative overhead costs associated with paper-based systems. Access to reporting analytics: Clearinghouses often provide analytics and reporting tools that offer insights into claim submission trends, denial rates, and reimbursement patterns. Healthcare providers can use this data to identify areas for improvement and optimize revenue cycle management strategies. Negotiation power with payers: Clearinghouses provide valuable data and analytics that healthcare providers can use during contract negotiations with insurance payers. Access to comprehensive claim data and performance metrics strengthens providers' negotiating position, potentially leading to more favorable reimbursement rates. It's also worth considering how partnering with a clearinghouse that integrates with other claims management solutions can deliver cost savings elsewhere in the revenue cycle, through optimized workflows and greater efficiency. 5. Integrated services “How does this service fit within our broader revenue cycle management (RCM) activities?” Claims management doesn't happen in isolation: everything from the patient billing experience to internal denials management should work together to improve the entire revenue cycle. It's important to look for a clearinghouse that can integrate with other RCM tools to improve first-pass rates and shorten payment cycles. Some clearinghouses can receive electronic remittance advice (ERA) and even automate payments, which could help providers get paid faster and further reduce the administrative load on staff. Clearinghouses can also integrate with a provider's electronic medical record and medical billing software to plug any gaps before claims are submitted. This integration ensures that accurate and up-to-date patient information is included in claims, reducing errors and denials. Additionally, clearinghouses may offer tools or APIs (Application Programming Interfaces) that allow EHR systems to transmit claims data directly to the clearinghouse platform, eliminating the need for manual data entry and improving efficiency. Clearinghouses should also integrate with practice management (PMS) systems to streamline claims submission. This interoperability enables a seamless transfer of patient and billing information from the PMS to the clearinghouse platform, automating claim generation and submission. Clearinghouses may even provide real-time claim status updates and remittance advice directly within the PMS. As noted, providers can accelerate claims and denial management by leveraging tools such as Claim Scrubber and ClaimSource. These tools draw on Experian Health's unrivaled dataset and analytics platforms, and integrate with Experian Health's other RCM solutions to verify and automate the information being added to each claim. Experian's patient identity solutions can also be used to keep patient data safe and secure, and cross-check demographic information to prevent hold-ups and streamline the entire process. Technological Trends and Innovations Technological advancements, particularly artificial intelligence (AI), are transforming claims denials management. AI-powered algorithms can analyze vast datasets to identify patterns, predict claim outcomes, and optimize workflows. These solutions enable healthcare providers to choose clearinghouses based on performance metrics, such as claim acceptance rates and denial management capabilities. By harnessing AI, clearinghouses offer unparalleled accuracy, speed, and intelligence, empowering healthcare organizations to maximize revenue and streamline healthcare operations. Glossary of Clearinghouse Terms Clearinghouse: A third-party entity that acts as an intermediary between healthcare providers and payers (insurance companies or government agencies) to facilitate the electronic processing of medical claims. EDI (Electronic Data Interchange): The electronic exchange of structured data between computer systems, used by clearinghouses to transmit medical claims data between providers and payers. HIPAA (Health Insurance Portability and Accountability Act): Federal legislation that sets standards for protecting and securing patients' health information, including electronic transactions such as those handled by medical claims clearinghouses. Claim Submission: The process of sending a request for reimbursement for healthcare services rendered to a patient to the payer through the clearinghouse. Claim Validation: The process of verifying the completeness and accuracy of medical claims data before submission to the payer, helping to reduce errors and denials. EDI Enrollment: The process by which healthcare providers register with a clearinghouse to exchange electronic data, including setting up connectivity and establishing secure transmission protocols. Rejection: When a submitted medical claim does not meet the requirements or standards set by the payer, resulting in a refusal to process the claim for reimbursement. Error Code: A numeric or alphanumeric code provided by the clearinghouse or payer to indicate the reason for a claim rejection, facilitating troubleshooting and correction of the issue. Electronic Remittance Advice: A document sent by the payer to the healthcare provider detailing the status of processed claims, including payment information and explanations for any denials or adjustments. Claim Status Inquiry: The process of querying the clearinghouse or payer to obtain information on the current status of a submitted medical claim, such as whether it has been received, processed, or paid. Claim Resubmission: The process of correcting and re-submitting a rejected or denied medical claim for reconsideration and processing by the payer. Batch Processing: The method clearinghouses use to handle multiple medical claims simultaneously, typically in large batches, to increase efficiency and reduce processing time. Payer List: A directory maintained by the clearinghouse containing information about the insurance companies and government agencies with which it interfaces for medical claims processing, including contact details and electronic submission requirements. Learn more about how Experian Health's medical claims clearinghouse and claims management solutions can help providers simplify and accelerate claims processing for faster payments and fewer denials. Learn more Contact us Contact Experian Health Complete the form below to be connected with a member of our Sales team. For Customer Support, including password resets, please visit our Support page.