Tag: claim denials

Manual insurance eligibility checks are slow, error-prone and a leading cause of claim denials. Find out how automated insurance verification delivers real-time accuracy, fewer billing errors and faster reimbursements — helping providers protect revenue and improve patient care.

Denial management is the process of addressing why healthcare claims are rejected or denied, instead of resolving them after they occur. This article explores denial management strategies, why outdated processes fail and how AI-driven solutions can help reduce denials and streamline workflows.

Top reasons for healthcare claim denials include missing or inaccurate data, lack of prior authorizations, and incomplete patient registration.

AI is reshaping patient access by reducing manual errors and preventing costly claim denials. Tools driven by AI and automation can streamline eligibility checks and coordination of benefits — helping providers improve efficiency, cut costs, and deliver a better patient experience.

Denied claims are rising fast, putting revenue and patient trust at risk. Automated claims management and AI-enabled tools are becoming essential for providers to reduce denials, accelerate reimbursements and improve operational efficiency.

AI is modernizing healthcare revenue cycle management by automating manual tasks, improving data accuracy and reducing denials. This Q&A explores how healthcare organizations can utilize AI-driven tools to strengthen their financial performance.

For patient access leaders at large healthcare organizations, the pressure is mounting and has been building for some time. Healthcare claim denials are climbing. Staffing is stretched, and the tools healthcare organizations have relied on for years are no longer enough. But what if providers could stop denials before they start? Welcome to the new era of denial prevention in healthcare, powered by predictive intelligence. Experian Health's innovative artificial intelligence (AI) solutions, Patient Access Curator and AI Advantage™, were designed to help organizations prevent denials before they occur. Explore how Experian Health is reshaping the way health systems manage Coordination of Benefits. Learn how automation and AI are eliminating manual errors, reducing denials and unlocking millions in recoverable revenue. Watch now > The denial spiral explained: A systemic challenge in revenue cycle management  Claim denials aren't just a back-end billing issue. They're a symptom of upstream breakdowns—often rooted in inaccurate or incomplete patient data at registration. According to Experian Health's 2024 State of Claims Survey, 46% of denials are caused by missing or incorrect information. And the cost of reworking a denied claim? $25 for providers and $181 for hospitals. The result? A denial spiral that drains resources, delays reimbursements, and frustrates patients and staff alike.  Why Epic users are especially vulnerable While Epic is a powerful EHR platform, many Epic-based organizations still rely on staff to make complex decisions at registration. Questions like: Is this coverage primary? Should discovery be run? Is this data accurate? ...are often left to frontline staff. This guesswork leads to inconsistent outcomes—and denials. What's needed is a layer of predictive intelligence that works within Epic to automate and correct data before it becomes a problem.  How Patient Access Curator fixes registration errors Patient Access Curator is that layer. Patient Access Curator is an all-in-one solution that automatically finds and corrects patient data across eligibility, Coordination of Benefits (COB) primacy, Medicare Beneficiary Identifiers (MBI), demographics and insurance discovery—within seconds. It integrates directly into Epic workflows, eliminating the need for staff to toggle between systems or make judgment calls on the fly. Instead of relying on registrars to catch every error, Patient Access Curator uses machine learning and predictive analytics to: - Identify and correct bad data in real time - Return comprehensive coverage directly into Epic - Reduce denials, write-offs, and vendor fees - Improve staff morale by removing administrative burden As one early-adopting Patient Access Curator client puts it: "If your current workflow still depends on frontline decisions, you're not just risking denials—you're building them in."  Predictive intelligence in healthcare: AI Advantage at work While Patient Access Curator fixes the front end, AI Advantage tackles the middle of the revenue cycle, where claims are scrubbed, edited, and submitted. At Schneck Medical Center, AI Advantage helped reduce denials by 4.6% per month and cut denial resolution time by 4x. The tool flags high-risk claims before submission and routes them to the right biller for correction. It also triages denials based on the likelihood of reimbursement, so staff can focus on the claims that matter most. Together, Patient Access Curator and AI Advantage form a closed-loop system: - Patient Access Curator ensures clean data at registration - AI Advantage predicts and prevents denials mid-cycle - Both tools integrate seamlessly with Epic and ClaimSource®  Why predictive denial prevention matters for patient access leaders  By implementing denial management technology and predictive intelligence, healthcare teams aren't just managing workflows; they're managing risk. Every inaccurate field, every missed coverage, every manual decision is a potential denial. Patient Access Curator and AI Advantage remove that risk by replacing guesswork with certainty. And the benefits go beyond revenue: - Fewer denials mean fewer patient callbacks and less frustration - Cleaner data means faster reimbursements and fewer write-offs - Automation means staff can focus on patients, not paperwork As Jason Considine, President at Experian Health, recently shared: "Our mission is to simplify healthcare. That starts by getting it right the first time, before a claim is ever submitted. With the power of AI and predictive intelligence, we're no longer waiting for denials to happen; we're helping providers proactively prevent them. Tools like Patient Access Curator and AI Advantage allow healthcare organizations to identify issues at the point of registration and throughout the revenue cycle, so teams can focus on care, not corrections. It's about working smarter, reducing risk and protecting revenue."  Denial prevention checklist: Preparing patient access teams for predictive denial prevention  Denial prevention is here, but what if billing teams aren't quite ready? To move toward a predictive denial prevention strategy, healthcare organizations can invest in the following five areas:   Audit front-end workflowsMap out every step from patient registration to claim submission. Identify where manual decisions are being made—especially around eligibility, COB, and insurance discovery. Ask: "Where are we relying on staff judgment instead of system intelligence?" Train staff on data quality awarenessReinforce the impact of inaccurate or incomplete data on downstream denials. Use real examples to show how a single missed field can lead to rework, write-offs, or patient frustration. Introduce the concept of "first-touch accuracy" as a team-wide goal. Evaluate Epic integration readinessAssess whether current Epic environments are configured to support automation tools like Patient Access Curator. Work with IT to assess whether the current setup allows for real-time data correction and coverage updates. Confirm that teams understand how new tools will integrate into their existing workflows, not replace them. Establish a denial prevention task forceBring together leaders from patient access, billing, IT and revenue cycle to align on goals. Assign ownership for key metrics like clean claim rate, denial rate, and registration accuracy. Use this group to pilot new tools like Patient Access Curator and AI Advantage and gather feedback from frontline users. Communicate the "Why" behind the changeFrame automation as a way to reduce burnout, not replace jobs. Highlight how tools like Patient Access Curator eliminate guesswork and free up staff to focus on patient care. Share success stories from peers (like Schneck Medical Center) to build confidence and momentum. The bottom line: Strategic denial prevention is the future Denial management is reactive. Denial prevention is strategic. For healthcare organizations using Epic, Patient Access Curator and AI Advantage offer a smarter, faster and more scalable way to increase reimbursements and improve the patient experience. Learn more about how Experian Health can help protect revenue, reduce staff burdens and reduce claim denials—starting at the first touchpoint. Learn more Contact us

Manual prior authorization workflows represent one of the most tedious and expensive aspects of the healthcare revenue cycle. However, despite access to automated prior authorization software, only 31% of providers use electronic prior authorizations, according to the Council for Affordable Quality Healthcare (CAQH). The CAQH predicts that providers who switch to automated prior authorization software could not only gain back valuable staff time, but also see significant cost savings. What is prior authorization and why is it important? In healthcare, prior authorizations are when providers and payers decide in advance if a patient's insurance plan will pay for a specific treatment. Prior authorizations are crucial to reimbursements and keeping revenue cycles on track. Providers that offer services without prior authorization are unlikely to receive reimbursement from the patient's insurer. This can result in unpaid medical bills, leaving billing teams chasing patient collections or writing off bad debt. During the prior authorization process, providers submit a rationale for a proposed treatment to the payer. The request is approved or denied based on certain criteria, including payer policies and medical necessity. The payer may reject a prior authorization request if the treatment or service isn't covered under the patient's insurance plan, if it's not considered medically necessary or if a more affordable alternative is available. Simple paperwork errors, like missed deadlines or incomplete documentation when submitting a prior authorization, may also result in a denial. Challenges of manual prior authorization processes Despite the importance of prior authorizations in the revenue cycle, tedious manual prior authorization processes present challenges for many healthcare providers. Some of the key obstacles providers face using manual prior authorization include: Heavy administrative burden Healthcare providers spend a significant amount of time starting, completing and revising prior authorization paperwork. An AMA survey found that 86% of physicians say prior authorization has increased healthcare resource usage. At the same time, additional AMA data reports that providers spend around 13 hours working on 39 prior authorizations each week, and nearly one-third of providers report that these prior authorization requests usually end up being denied. Changing payer policies Keeping up with multiple payers and ever-evolving payer policies adds strain on staff and ultimately results in prior authorization denials. Changes are often unannounced, making it hard for providers to stay on top of updates. As a result, prior authorization submissions aren’t always accurate and may be based on outdated rules. This can lead to instant rejection and wasted time correcting and resubmitting requests. Inefficient workflows Prior authorization requirements can be complicated, especially when providers are juggling different payers, standards and service lines. Coping with these complexities often puts strain on manual systems, especially when multiple staff and notetaking methods are involved. Staff members may each get different pieces of information from payer websites (or over the phone) and not have the ability to benefit from their shared knowledge efficiently. Navigating communication hurdles and rapid payer information changes can result in workflow inefficiencies that snowball quickly. How prior authorization software can improve efficiency Replacing manual prior authorization processes with automated prior authorization software can help providers improve efficiency. Here are some key ways providers benefit from automated prior authorization solutions, like Experian Health's Authorizations. Reduces manual interventions: This solution limits guesswork, human errors, and misinterpretations by automating data originating from the EMRs. Automation saves staff time and energy and prevents frustration. Stays current with latest payer policies: The prior authorization system stays up-to-date with the latest regulations and payer requirements. Automatic updates provide staff with the most current information, eliminating the need for staff to visit multiple payer websites or cross-check data by hand. Provides real-time updates: Providers can promptly clear authorizations for service by proactively identifying authorization status as pending, denied or authorized. This allows physicians to make timely treatment plans and for patients to avoid disruptions in care. Reduces risk of denials: Through automation, electronic prior authorization software ensures the accuracy and completeness of submissions by automatically checking with payers and vendors to validate that the authorization is on file. Payers and providers also get a shared view of account information, reducing the need for prolonged discussions about the status of authorization and rework requests. Key features to look for in prior authorization software When implementing prior authorization software, look for a solution that offers a wide range of features to automate and streamline the prior authorization process. Experian Health's prior authorization solution, Authorizations, for instance, offers healthcare providers the following key features: Real-time knowledgebase: Access to up-to-date prior authorization requirements and criteria in the National Payer Rulesets Submissions support: Removes guesswork and directs users to the correct payer portal based on procedure Automated inquiries: Automates the prior authorization payer inquiry process Enhanced workflow: Dynamic work queues display status and guide users through next steps Postback: Allows users to easily send authorization status, number and validity dates to health information systems (HIS) and practice management systems (PMS) Image storage: Receives and securely stores payer responses in an integrated document imaging system Reconciliation: Provides insights into authorization variations and helps resolve them, so staff can take proactive steps to prevent denials and appeals Integration with electronic health records and billing systems: Why it matters Providers often choose a prior authorization platform that seamlessly integrates with existing Electronic Health Records (EHR) and billing systems for maximum efficiency. Solutions like Experian Health's automated prior authorization management tool, Authorizations, easily adapt to existing processes. This eliminates the need for a complete workflow overhaul and minimizes the learning curve for staff. Embracing prior authorization software for a more efficient revenue cycle Revenue cycle leaders who implement prior authorization automation strategies could see significant savings – $494 million annually as an industry, according to CAQH data.  Claims and revenue management processes are often complex and outdated, costing healthcare organizations time and money. High denial rates and slow reimbursements can hurt cash flow and get in the way of financial stability. Automating prior authorization can reduce claim denials, speed up reimbursements and improve the bottom line. Learn more about how Experian Health's electronic prior authorization software, Authorizations, uses automation to achieve greater consistency and efficiency for healthcare organizations. Learn more Contact us

Managing claims efficiently—and reducing denials—remains one of the biggest challenges for healthcare providers. Statistics reveal that 46% of denials are caused by missing or inaccurate data, as highlighted by Experian Health's 2024 State of Claims Survey. For providers, these denials translate into endless follow-ups with patients, staff burnout, rising bad debt (which has increased by 7% year-over-year), and slim revenue margins. Reworking a denied claim costs providers an average of $25 and hospitals $181—an expense that is difficult to justify. Introducing Patient Access Curator: Automated claims accuracy from day 1 Fortunately, there is now a way to ensure claims are processed accurately from the start, without excessive effort: Patient Access Curator (PAC), Experian Health's groundbreaking new tool that uses artificial intelligence (AI) to revolutionize the claims process. As a central component of Experian Health's Patient Access portfolio, this innovative solution automates front-end processes, identifies incorrect data upfront, and resolves inaccuracies in real time, preventing costly claim denials before they occur. Introduced in early 2024, the curation tool is getting the attention of revenue cycle leaders at health systems and laboratories, with good reason.  This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds.  On-demand webinar: Reimagining patient access — AI at the epicenter of coordinated benefits management Explore how automation and AI are eliminating manual errors, reducing denials and unlocking millions in recoverable revenue. Built-in AI for more accurate data and seamless claims denial prevention 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 on 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. Patient Access Curator takes on these tasks seamlessly, and right within Epic workflows. From patient demographics and eligibility checks to coordination of benefits (COB) primacy, Medicare Beneficiary Identifiers (MBI), and insurance discovery, the system automates these essential processes, providing precise data within moments. This solution ensures data integrity from the moment of registration by replacing manual guesswork with advanced AI-driven technology. This reduces the frequency of denials, minimizes A/R write-offs, and curtails vendor fees. Beyond enhancing efficiency, the tool safeguards the financial health of healthcare providers.  Jason Considine, President of Experian Health, says, "Our mission is to simplify healthcare. Patient Access Curator's advanced AI technology equips providers to address claim denials more effectively and efficiently than ever before."  Say goodbye to manual work with instant eligibility and insurance verification Patient Access Curator simplifies operations for billing teams, healthcare staff and patients. By removing administrative hurdles, staff can focus on patient engagement, rather than spending time on paperwork, phone calls and browsing websites for data. The outcome is improved satisfaction for both healthcare providers and their patients.  "We know this technology is revolutionizing the healthcare industry," shares Jordan Levitt, Senior Vice President at Experian Health. Levitt, who developed the AI-powered data capture technology, explains, "By delivering faster, more accurate results, providers can improve financial solvency while giving staff and patients a better experience."  Gone are the days of asking patients for insurance cards or verifying numbers and dates that might be inaccurate. With this solution, registrars and billing teams can be confident in the data they collect, right from the start.  PAC was created to replace the manual guesswork that often bogs down eligibility and insurance verification processes. From patient demographics and eligibility checks to COB primacy, MBI, and insurance discovery, this solution automates these critical touchpoints, delivering accurate data in seconds.  Fewer denials, faster reimbursements  The impact on denial prevention is unparalleled. Patient Access Curator ensures fewer claim rejections and faster payer reimbursements by identifying and correcting bad data across eligibility, COB, and discovery at the start of the revenue cycle. Providers are left with more retained revenue, which can be reinvested into what truly matters: patient care.  Patient Access Curator: Key features that set it apart Patient Access Curator differentiates itself as a comprehensive, all-in-one product that simplifies the most complex aspects of claims management. Key features include:  Real-time data correction: Fixes inaccurate data instantly without staff intervention.  Comprehensive coverage: Finds and corrects bad data across eligibility, COB primacy, MBI, demographics, and insurance discovery.  Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps Coordination of Benefits: 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: 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: The platform can quickly check and correct patient contact information.  Seamless integration: Automatically updates host systems (Epic) with verified and corrected coverage data in seconds.  The results? Fewer clicks, faster workflows, and more accurate billing processes. PAC doesn't just prevent claim denials; it transforms how healthcare teams approach patient access and revenue cycle management.  Proven ROI: How Patient Access Curator delivers $100 million boost to Exact Sciences Explore how Patient Access Curator powered a $100M improvement at Exact Sciences by automating insurance discovery and reducing claim denials. Improve financial health by focusing on patient health By eliminating redundant administrative questions, Patient Access Curator allows patients to focus on their health rather than the complexities of billing and coverage. Meanwhile, healthcare staff enjoy a boost in morale, thanks to fewer manual tasks and more efficient workflows—a benefit that can lead to higher staff retention over time.  Patient Access Curator is more than a tool; it's a game-changer for healthcare organizations looking to protect their revenue while delivering a better, more seamless experience for both staff and patients. Say goodbye to manual guesswork and hello to a smarter, faster, and more reliable way to manage claims. With PAC, healthcare organizations can finally get claims right from the start, without the hassle.  Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us