Tag: claim denials

Medical billing errors are common problems that can lead to significant financial losses for healthcare organizations. While most medical billing errors are preventable, outdated systems, complex processes and human errors often result in delayed or denied claims. Faced with ever-increasing overhead costs, workforce challenges and growing volumes of data, healthcare leaders will need to implement modern medical billing software solutions to improve revenue cycle management (RCM) medical billing efficiencies, without adding costly headcount or overhead. This article reviews the role modern medical billing software plays in revenue cycle management and how RCM leaders can use it as a top defense to prevent costly claim delays and denials. What is medical billing software in revenue cycle management? Medical billing software is a critical tool healthcare organizations use to streamline patient billing and collections in revenue cycle management. Revenue cycle leaders know that outdated and complex billing processes can wreak havoc on the entire revenue cycle and waste valuable staff time. However, medical billing in revenue cycle management allows providers to optimize the entire revenue cycle — from pre-visit insurance verification and cost estimates through patient billing and collections. Automated medical billing processes in the revenue cycle can help improve efficiencies, reduce errors, and create more reliable collections processes. This allows healthcare organizations to deliver better patient care while protecting their bottom line. How software powered by artificial intelligence (AI) improves medical billing efficiency AI-powered software helps providers manage many types of complex revenue cycle billing processes — from claims management to collections. Providers that embrace AI often benefit from streamlined medical billing processes, fewer claim denials, real-time eligibility verification, better data insights and productivity boosts. For example, AI-powered software can streamline medical billing by automating repetitive tasks, like insurance verification checks, so providers can prevent and catch errors, speed up reimbursements and stretch strained resources. On the front end, with single-click AI-driven data capture technology, running multiple manual eligibility queries is no longer necessary. Now, with solutions like Patient Access Curator, patient details can be verified quickly and accurately. Patient Access Curator leverages AI and machine learning to automatically handle eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, insurance discovery and more, with just one click. This saves staff hours and reduces human errors that can lead to claims denials and costly delays later on. Ken Kubisty, VP of Revenue Cycle at Exact Sciences, shares how Patient Access Curator helped their organization reduce claim denial errors and added $75 million in insurance company collections. AI-driven predictive analytics solutions, like AI Advantage™, can also help staff identify claims that may be at risk of denial, so potential issues can be handled before submission — saving even more staff time. When admin overhead is minimized, there's less burnout and less stress. Staff can focus on higher-priority tasks, and healthcare organizations can see productivity increase overall. Preventing claims denials with better billing solutions Claims denials are on the rise with healthcare organizations being left on the hook for delayed or unpaid claims. In the State of Claims 2024 report, 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of cost in reworks and lost revenue. Nearly half of providers say patient information errors are a primary cause of denied claims. Errors are common during pre-visit insurance verification due to error-prone manual processes, but can happen at any point during the collection process. Medical billing software helps providers reduce errors and submit cleaner claims right from the start and catch errors before they become costly problems. Here are some of the key ways medical billing software like Experian Health's Patient Access Curator solution helps providers head off claims denials before they happen.   Eligibility checks: Automatically verifies patient eligibility and updates records in real-time to ensure patient information is accurate before claims submission. Coordination of Benefits (COB) verification: Discovers and verifies secondary and tertiary insurance coverage to reduce the risk of COB-related denials while using AI-powered technology to seamlessly integrate with a provider's eligibility verification process. Medicare Beneficiary Identifiers (MBIs): Updates MBIs to confirm patient records are correct and compliant with Medicare requirements while using AI-driven technology and automation to find and correct patient identifiers automatically. Demographics: Patient demographic information is corrected and updated using in-memory analytics and Experian Health's proprietary algorithm to accurately find and fix contact information. Insurance Discovery: Identifies and corrects missing or incorrect insurance information to ensure claims are submitted with the most accurate information available. Discover how Experian Health's revolutionary AI-powered revenue cycle solution is turning denial management into denial prevention. Patient Access Curator solves for missing or correct data in real-time at registration and scheduling, creating a smooth, clean claim process and lowering denials by double digits. Optimize efficiencies in claims management through AI Experian Health customers currently using ClaimSource® can now improve their claim management strategy — before claim submission and after denial. With AI Advantage™ Predictive Denials and Denial Triage, providers can leverage historical claims data and Experian's deep knowledge of payer rules to continuously adapt to an ever-changing payer rules landscape.AI Advantage's - Predictive Denials component reduces denial rates, detects payer changes and empowers staff to focus on highest-priority claims, while AI Advantage's - Denial Triage identifies denials with the highest reimbursement potential and uses AI to segment denials, eliminating guesswork for billers. Watch the video to learn more about the two components that make up AI Advantage, and how healthcare organizations can transform the reimbursement process and decrease claim denials for good. Medical billing software is only getting smarter and faster Upgrading outdated manual medical billing processes results in cleaner claims, improved staff efficiencies, better care and improved patient satisfaction. Today's AI-driven technology brings medical billing in RCM to the next level, enabling time-strapped providers to do even more with less. Now busy providers can streamline manual processes that used to take hours into just seconds. With this new technology, patient information is accurate when claims are submitted, eliminating the need for costly reworks and hits to the bottom line. As more providers adopt AI technology for RCM in medical billing and software solutions get more sophisticated, providers will see new success stories in its power to help healthcare organizations optimize the entire revenue cycle. Learn how tools like Patient Access Curator and AI Advantage can help healthcare organizations prevent claim denials and improve medical billing in RCM. Learn more Contact us

“Reducing denials upfront would improve our revenue, which could be channeled into current and future investments that support our mission.” —Joshua Gayman, Revenue Cycle Manager at UT Medical Center Challenge The University of Tennessee Medical Center (UT Medical Center) is a leading 710-bed acute care hospital with a rich history of exceptional patient care and award-winning services. During the pandemic, the hospital faced revenue losses of around $45 million that put serious strain on its capacity to invest in bigger and better facilities. UT Medical Center needed to find a strategy to recover some of this revenue by reducing claim denials at the point of patient registration. UT Medical Center relied on eligibility checks that often missed errors in patient registration, resulting in increased claims denials, costly reworks, and wasted staff time. The hospital urgently needed a solution to help staff identify and resolve potential patient registration errors in real time to prevent denials before they occur. Finding a more efficient way to capture accurate patient and benefits data would be essential. Proactively preventing claim denials would provide the hospital with a much-needed boost in cash collections and free up staff to focus on patient care. Solution To address its claims denials challenge, UT Medical Center partnered with Experian Health and implemented Registration QA, a solution designed to find and fix registration errors upfront. Now, when patients first arrive, front-end staff enter their data to verify insurance. If Registration QA finds an error, it alerts staff in real-time so they can resolve it within 72 hours. Alongside more than 400 alert rules curated by Experian Health, UT Medical Center also built custom alerts based on the organization's specific requirements, using demographics and benefits data. The tool easily integrates with existing workflows, and its configurable dashboard gives UT Medical Center Management detailed insights into department performance and allows staff to track trends and identify areas for improvement. This proactive approach to correcting errors significantly reduces the risk of downstream denials and helps patient registration staff take proper corrective actions for their errors without management intervention. More accurate patient registration is also better for patients, as fewer errors make for a smoother intake experience. Outcome UT Medical Center successfully optimized patient registration by using Registration QA to identify registration errors before and at the point of service, reducing denials and boosting revenue. In the 12 months after implementing Registration QA, UT Medical Center saw the following results: Now that registration errors can be identified before and at the point of service, UT Medical Center has seen initial denials drop from an average of $5 million per month in 2022 to just $1.7 million in 2023, representing a 66% decrease in average monthly initial denials value. Cash write-offs also decreased, dropping 57% from an average of $1 million to just over $400K, helping the organization keep bad debt low. Gayman notes that UT Medical Center's partnership with Experian Health was central to its success. Experian Health shared the organization's vision and provided weekly support to help realize it. They developed a customized curriculum to make sure staff were confident using Registration QA and offered insights into what was happening more widely in the industry, so UT Medical Center's team could benchmark their performance against similar organizations. Thanks to these savings, the hospital can increase its capacity to invest in new projects and deliver operational excellence, while improving patient satisfaction. Find out more about how Registration QA helps healthcare organizations minimize denials and increase cash flow through accurate patient registration. Learn more Contact us

“You know when the Patient Access Curator went live because you can see it in our stock price. It helped us drive a $100 million bottom-line improvement within two quarters.” —Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences Challenge Exact Sciences is a prominent cancer diagnostics laboratory with an annual net revenue of around $2.6 billion, that's best known for its flagship cancer screening test, Cologuard. After a period of rapid growth demand for its test, Exact Sciences faced the difficult task of collecting accurate patient data and verifying insurance eligibility at scale. Anticipating a 25% growth in annual testing volumes, Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences, says the organization “needed an automated, real-time solution" to capture accurate data from the start. The company had four specific objectives: Improve the accuracy of patient insurance data to reduce errors and denials. Streamline processes to handle rising testing volumes without increasing headcount. Reduce claim denials to bring in more revenue (especially those related to eligibility and timely filing). Ensure accurate identity verification in lab settings, where patient, physician and lab data aren't unified within a single data management system. Watch the webinar: Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. Solution In need of a single solution to solve multiple challenges, Exact Sciences turned to Experian Health's Patient Access Curator. This new product provided the team with a way to run inquiries for eligibility, Medicare beneficiary identifiers, coordination of benefits, insurance discovery and demographic data with a single click. Instead of juggling multiple products and vendors, registrars would be able to capture and verify patient data in a single transaction. Through automation and machine learning, Patient Access Curator could deliver results in less than 30 seconds and help submit clean claims the first time – reducing the risk of denials even as volumes increased. Experian Health's implementation experts configured the tool to Exact Sciences' needs, integrating over 4,000 payer plans nationwide and customizing parameters for real-time eligibility checks and data validation. Experian Health also delivered staff training to support the transition to the new system. Watch the video: See how Experian Health's Patient Access Curator streamlines patient access and billing, addressing claim denials, data quality and real-time corrections to boost your business's bottom line. Outcome Thanks to Patient Access Curator, Exact Sciences achieved the following results: 15% increase in revenue per test due to accurate eligibility and fewer denials 4x business volume without increasing headcount 50% reduction in denials and major improvement in timely filings $100 million added to the bottom line in 6 months Ken Kubisty, VP of Revenue Cycle at Exact Sciences, shares how Patient Access Curator improved eligibility processes, reduced errors and more. Overall, Kubisty credits Experian Health's Patient Access Curator for helping Exact Sciences overcome critical pain points resulting from data errors and eligibility issues. Solving for bad data quality with real-time data correction freed staff from tedious manual work, ensuring faster, more accurate claims processing – all without growing headcount. After implementing Patient Access Curator, the company is ready to scale and handle growing volumes efficiently, say goodbye to late filing denials and scale smarter. For Kubisty, this highlights how technology drives efficiency and sustainable growth. Learn more about how Patient Access Curator helps patient access teams prevent claim denials by solving for bad data quality with real-time data correction. Learn more Contact us

As margins tighten, traditional revenue cycle management strategies are on shaky ground. Many healthcare providers are turning to automation and AI to simplify payments, prevent revenue loss and protect profits. This article breaks down some of the most common revenue cycle management (RCM) challenges facing healthcare leaders and offers a practical checklist to optimize patient access, collections and claims management, while building a resilient and patient-centered revenue cycle. Common challenges in revenue cycle management Revenue cycle management is how healthcare organizations handle the financial side of patient care, from patient billing to claims management. Healthcare providers rely on RCM to ensure they are properly paid, so they can keep the lights on, pay their staff and deliver quality patient care. Are traditional RCM strategies still fit for purpose? Consider some of the current challenges: Patients are responsible for a larger share of costs due to high-deductible health plans. How can providers help them understand their financial obligations and make it easier to pay without hurting their experience? Minimizing claim denials is a daily focus, thanks to constantly changing policies and regulatory updates. How do revenue cycle teams keep up with payers? Staffing shortages remain on the agenda. How can providers ease pressure on staff to maintain productivity and morale? There's also the question of how to turn mountains of data into actionable insights. How do teams interpret it correctly to identify bottlenecks and opportunities for improvement? Automation and AI offer a way through. When implemented thoughtfully, these tools can speed up processes, reduce errors and clear operational roadblocks for a more resilient revenue cycle. The following revenue cycle management checklist includes some of the key questions to consider along the way. Checklist for improving revenue cycle management Automating patient access Can patients book appointments online? Does the online scheduler automate business rules to guide patients to the right provider? Are patient identities verified at registration and point of service? A healthy revenue cycle starts with efficient patient access. According to the State of Patient Access 2024, 60% of patients want more digital options for scheduling appointments, managing bills and communicating with providers. Providers who see improvements in patient access also credit automation, which speeds up intake and improves accuracy. A good first step is to replace paper-based processes with online self-scheduling and self-service registration. These tools make life easier for patients, boosting satisfaction, retention and engagement. Behind the scenes, Experian Health's new AI-powered tool, Patient Access Curator, helps providers get paid faster by verifying and updating patient information with a single click – accelerating registration and paving the way for faster reimbursement. Register now: Exact Sciences and Trinity Health will share how Patient Access Curator is redefining patient access in this upcoming webinar. Optimize patient collections with data and analytics Are patient estimates provided upfront? Are notice of care requirements being addressed? Are patients offered appropriate financial plans and easy ways to pay? With more financial responsibility resting on patients' shoulders, patient collections are under the spotlight. The State of Patient Access report shows that upfront estimates and clarity about coverage are top priorities for patients, because when they know what they owe, they're more likely to pay on time. Implementing tools to promote price transparency and easy payment methods should feature in any RCM checklist. With Coverage Discovery, healthcare organizations can run checks across the entire revenue cycle to find billable commercial and government coverage that may have been forgotten, to maximize the chance of reimbursement. Meanwhile, Patient Payment Estimates offers patients clear, accessible estimates of their financial responsibility before treatment, so that hose who need financial assistance can be directed automatically to payment plans and charity options. Case study: How UCHealth secured $62M+ in insurance payments with Coverage Discovery® Improve claims management to reduce denials Are high-impact accounts prioritized? Are remittances reconciled with payments received? Does claims management software generate real-time insights and reports? With 73% of healthcare leaders agreeing that denial increased in 2024, and 67% saying it takes longer to get reimbursed, claims management is a great use case for automation. ClaimSource®, ranked Best in KLAS in 2024 for claims management, automates the entire claims cycle in a single application. It integrates national and local payer edits with custom provider edits to verify that each claim is properly coded before submission. By focusing on high-priority accounts, providers can target resources in the most effective way to ensure a higher first-pass payment rate. A major advantage for ClaimSource users is access to AI Advantage™. This tool utilizes AI to “learn” from an organization's historical claims data and trends in payer behavior to predict the probability of denial. It also segments denials so staff can prioritize those that are most likely to be reimbursed, reducing the time and cost of manual appeals and rework. Case study: After using AI Advantage for just six months, Schneck Medical Center reduced denials by an average of 4.6% each month, and cut rework time from 12 to 15 minutes per correction to under 5 minutes. Benefits of implementing a revenue cycle management checklist The key to choosing the right RCM tools and technologies is to build the strategy around what patients need most. A clear, transparent and compassionate billing experience is more manageable for patients and helps providers get paid faster. An RCM checklist helps teams stay focused on the tasks that matter. Providers can build on the suggestions above by choosing the key performance indicators (KPIs) that align with their specific goals. Metrics like financial performance, billing efficiency and collections rates can be combined to guide resource allocation, drive improvements and speed up reimbursement. With a well-designed checklist informed by clear KPIs, revenue cycle leaders can keep their teams on track and take their organizations from “surviving” to “thriving.” Learn more about how Experian Health's revenue cycle management tools can help healthcare providers meet current challenges, improve the patient experience and increase cash flow. Learn more Contact us

Patient eligibility verification is a critical part of the healthcare revenue cycle. It can help prevent errors with claim submissions, reduce denials, boost the bottom line, and help patients understand what their insurance will cover. However, checking insurance eligibility isn't always efficient or accurate, thanks to outdated systems and complicated manual processes. Ever-evolving payer requirements and new regulations, like the No Surprises Act, add even more complications during insurance eligibility checks. In 2024, providers also treated more patients than they did five years ago, making it harder to keep up with patient eligibility verification. This growing volume of patients have more complex health issues and may struggle to afford medical bills, putting a more pressing urgency on providers to run accurate eligibility checks before service. Having the right health insurance eligibility verification solution can make or break a provider's revenue cycle and allow staff to stay focused on patient care instead of digging for insurance information and correcting errors. This article takes a closer look at why patient eligibility matters, common challenges providers face and strategies to improve insurance eligibility checks, reduce payment delays and minimize denials. What is patient eligibility verification? Patient eligibility verification is an administrative process providers use to check whether or not patients have active medical insurance. It's typically completed before service occurs to confirm coverage for treatment and care. Sometimes called a health insurance lookup, the eligibility check verifies different aspects of a patient's coverage, including insurance status, coverage details and medical service benefits. During patient eligibility verification, billing information is also confirmed. Why is it critical for healthcare providers? Patient eligibility verification offers providers a first line of defense to protect revenue cycles against revenue leakage. It can help healthcare organizations with accurate billing, reduce claims denials and avoid footing the bill for uncompensated care. When eligibility checks are conducted diligently, providers see improved cash flow, staff efficiency is gained, the risk of bad debt is lower, and patients are empowered with accurate upfront estimates. The importance of patient eligibility verification Claim denial rates are growing and show no signs of slowing down. Experian Health's State of Claims 2024 survey reports that nearly three-quarters of respondents saw a rise in denials, with four in ten saying claims are denied 10% of the time. Eligibility issues, along with missing or inaccurate data, are a top reason for denials, according to 15% of providers surveyed. A reliable eligibility verification process is crucial to minimizing the claim denials, rework and billing errors that arise from inaccurate insurance information. It also lets patients know their financial responsibility upfront so there are no surprises when the bill comes. This trust and transparency fosters positive patient-provider relationships while ensuring patients get the care they need and providers get paid. Common challenges in patient eligibility verification Findings from Experian Health's State of Patient Access and State of Claims surveys point to several common challenges in patient eligibility verification. Evolving payer policies and pre-authorization requirements Insurance provider prior authorization requirements change often, making it hard for providers to keep pace. More than 75% of providers report an increasing amount of payer policy changes, and secondary eligibility checks take time and impact efficiency. When a necessary authorization is missed due to manual verification or rushed eligibility checks, it can result in denial, delayed payment and extra work – especially when care is urgent. Incomplete or outdated insurance information Insurance details in the provider's system don't always match the payer's record. This can happen for a wide range of reasons, including job switches, insurance plan changes or patients not being aware of or forgetting to mention secondary coverage. When these changes aren't caught before service, they can lead to rejected claims, billing delays and extra work for staff.  More than four in ten providers report adding at least 10 minutes of staff time per incomplete eligibility check. Inadequate technology to verify eligibility Staff must often wrangle a wide range of disjointed solutions, processes and logins during eligibility checks. While more than 70% of providers feel their organization runs insurance verification checks efficiently and accurately, nearly 60% of providers still use at least two different tools to gather the necessary patient information for claim submission. This can make navigating patient eligibility verification tedious and error-prone, and leads to staff burnout, denied claims and patient dissatisfaction. Strategies to improve patient eligibility verification In today's changing health insurance landscape, providers need to pay more attention than ever to their patient eligibility verification processes. Accurate and timely insurance verification streamlines the claims process, clarifies how bills will be covered (or not) ahead of time and helps patients prepare to pay their bills. Adopting the following strategies to improve patient eligibility verifications can help providers reduce the risk of denied claims, improve the revenue cycle and create positive patient experiences. Automate eligibility verification processes Verifying coverage early in the billing process increases the chance of submitting clean claims the first time. However, it can be tedious for providers to navigate outdated methods like online portals, file batching, automated systems and stay on top of ever-changing payer policies. Automated eligibility verification software helps providers optimize intricate insurance checks, access verified and comprehensive resources to confirm eligibility (with solutions like the MBI Lookup tool), and improve efficiency. Automatically track changing payer policy requirements With payer requirements undergoing constant updates, providers need to have access to solutions that keep up in real-time. Eligibility Verification, for example, seamlessly connects to more than 900 payers and features advanced patient matching tools. It can also be used with Experian Health's automated prior authorization tool, which tracks national payer requirements and flags providers when mandatory pre-authorization information is missing. Offer upfront, accurate cost estimates Patients want to know their financial responsibility up front. When armed with accurate estimates that help patients understand their coverage, co-pays and deductibles, more than 80% of patients say it helps them prepare financially. Eligibility tools allow providers to create more accurate estimates based on actual insurance coverage. This helps patients know what they're responsible for out-of-pocket and reduces surprise billing. Patient eligibility verification is more critical than ever in ensuring smooth and efficient revenue cycle management. With rising patient volumes, evolving regulations and other challenges impacting revenue cycles, providers need to maintain accurate insurance eligibility checks to reduce costly errors, streamline workflows and improve claims success rates. More importantly, accurate eligibility checks empower healthcare staff to focus on delivering quality care, while helping patients better understand and manage their financial responsibilities. Find out more about how Experian Health's insurance eligibility verification solution helps revenue cycle managers prioritize reimbursements with automated eligibility checks. Learn more Contact us

Patients expect clear information about their insurance coverage when they visit their healthcare provider, but too many leave feeling confused and financially underprepared. Experian Health's State of Patient Access 2024 survey reveals that 56% of patients struggle to make sense of their insurance coverage without provider assistance, while 61% say improving coverage explanations is the most urgent challenge in patient access. For providers, the financial fallout from missed insurance eligibility checks is even more pressing, with 15% of providers citing eligibility issues as one of their top three reasons for denials. Accurate eligibility checks are crucial to keep the revenue cycle on track. This article highlights common challenges and current best practices for improving eligibility verification. Could automated insurance eligibility checks give patients and providers the financial clarity they're looking for? What are insurance eligibility checks? Insurance eligibility checks are carried out pre-service to confirm that a patient has active insurance that will cover their planned treatment and care. Verifying insurance status, coverage details and benefits in advance ensures that the proper claims and bills are sent to the right recipient. Patients and providers get early warnings of coverage limitations and potential out-of-pocket costs, which helps patients access care without any financial surprises. Without these checks, healthcare organizations may deliver services to patients without active coverage — and with no clear path to payment. Therefore, a reliable eligibility verification process is essential to minimize the claim denials, rework and billing errors that often stem from inaccurate insurance information. How do insurance eligibility checks impact revenue cycle management? In the healthcare revenue cycle—which revolves around who pays, when and how—insurance eligibility checks are a first line of defense against revenue leakage. They're a proactive step toward establishing smooth claims and collections processes so no dollar goes uncollected or is lost to avoidable admin overhead. Prioritizing robust eligibility verification systems, as patient survey respondents advocate, is not just an operational necessity; it's a strategic safeguard against slow payments, patient dissatisfaction and financial instability. The insurance eligibility check process The eligibility verification process typically begins by confirming the patient's contact information to match their insurance card and electronic health record details. Staff then initiate an eligibility request to confirm active coverage. Once confirmed, they check that the plan covers proposed services, including any pre-authorization requirements, and review coverage limits to ensure the patient hasn't exceeded annual or lifetime caps. If applicable, providers also cross-check for Medicare eligibility using the Medicare Beneficiary Identifier (MBI) to identify any additional coverage. Common challenges with insurance eligibility checks Findings from Experian Health's State of Patient Access and State of Claims surveys illustrate the extent of the eligibility challenge, pointing to three main areas for improvement: Outdated or incomplete insurance information Sometimes, the insurance details in the provider's system don't match the payer's record. Patients may change jobs, switch insurance plans, or have secondary coverage they didn't know about or forgot to mention. If these changes aren't caught up front, it can lead to claim rejections and billing delays. Besides the obvious problem of lost revenue, this challenge incurs extra work: 43% of providers report that incomplete checks add at least 10 minutes per eligibility check. Changing payer policies and pre-authorization requirements Keeping up with each insurance provider's prior authorization requirements is challenging, especially if the patient's treatment is urgent. Missing a necessary authorization can lead to a denial, delayed payment and extra work. More than three-quarters of providers say payer policy changes are increasing, but only 10% are using automated tracking as part of their denial management strategy. Is there an opportunity to automate prior authorizations and eligibility verification to tackle denials? Inadequate tools to verify eligibility More than 7 in 10 providers say their organization runs eligibility checks quickly and accurately, but significantly fewer think their revenue cycle management technology is as good as it could be. 59% of providers are using at least two different solutions to collect all the necessary patient info for a claim submission. Tool overload is a real problem, as staff must wrestle with different platforms, processes and logins to get the eligibility information they need. Best practices for effective insurance eligibility checks  To tackle these challenges, providers can use automation to streamline their verification workflows. Some key practices for more reliable and efficient insurance eligibility checks include: Automate real-time eligibility checks for faster, more precise verification: For example, Eligibility Verification automatically verifies insurance coverage and plan-specific benefits information before and at the time of service. This not only speeds up registration, but also catches any potential coverage gaps before services are provided. Automation also helps minimize manual work and reduces the risk of human errors that can lead to claim denials. Track payer policy changes automatically: Insurance verification software helps providers keep up with ever-changing payer requirements. Eligibility Verification connects to more than 900 payers with advanced search, to maximize the likelihood of matching patient information. This can be used alongside Experian Health's automated pre-authorization tool, which dynamically updates national payer prior authorization requirements and flags when something is missing. Give patients upfront, automated price estimates: More than 80% of patients say upfront pricing estimates help them prepare for costs. Automating eligibility checks and patient payment estimates help patients understand their coverage, co-pays and deductibles, so they know what to expect when their bill arrives. This improves transparency, boosts patient satisfaction and accelerates collections. Implementing these best practices helps ensure smooth claim submissions and reduces denials due to eligibility issues, ultimately supporting a healthier revenue cycle. Case study: How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks Within just five months of implementing Eligibility Verification, Providence Health had saved $18 million in potential denials. Read the case study to see how automated insurance eligibility checks reduced denials, increased staff productivity and boosted patient satisfaction. How Experian Health can help healthcare organizations improve eligibility checks While healthcare affordability remains a pressing concern for patients and providers, quickly and accurately verifying insurance eligibility will remain among the top priorities for both groups. Experian Health aims to simplify the process with automated Eligibility Verification. In addition to reducing payment delays and denials, its streamlined workflows support higher patient volumes, especially as patients have more complex insurance arrangements and take on greater financial responsibility. One significant advantage is the ability to provide extra support for the growing number of patients who may be eligible for Medicare. Medicare eligibility checks can be complicated, particularly if patients don't know which component they qualify for. Eligibility Verification includes an optional MBI lookup service to find and validate the patient's MBI number without requiring a manual search. Find out more about how automating insurance eligibility checks verifies coverage quickly and accurately — giving patients and providers early clarity about how the cost of care will be covered. Learn more Contact us

Experian Health's State of Claims 2024 report reveals a worrying trend in healthcare claim denials, with nearly three-quarters of survey respondents reporting a rise. Around four in ten say claims are denied 10% of the time, with one in ten seeing denial rates above 15%. Denials at this scale, driven by various claim denial reasons, represent billions of dollars in lost or delayed reimbursements, so it's no wonder that reducing health insurance claim denials tops healthcare providers' “must-fix” list. However, despite being highly motivated to resolve the challenge, many organizations need more support to overcome operational roadblocks. Prior authorizations are taking longer to come through. Payer policy changes are more frequent. Patient information is increasingly inaccurate. For 65% of respondents, submitting clean claims is more complex than before the pandemic. With some wrangling more than three technological solutions and others lacking confidence about using automation and AI, providers seem to be struggling to find the sweet spot when tackling denials. This article looks at the reasons for increased claim denials, as well as how automation and artificial intelligence (AI) can help healthcare providers overcome these obstacles to increase operational efficiency and improve cash flow. Major operational challenges leading to increased claim denials Clarissa Riggins, Chief Product Officer at Experian Health, says that many providers are increasingly concerned that payers won't reimburse costs as denial rates increase, when discussing the State of Claims 2024 report. These concerns reflect operational challenges, including difficulty keeping track of pre-authorization requirements, inability to keep up with rapidly changing payer policies and inadequate front-end data collection. While staffing shortages are not among the top three claim denial reasons as they were last year, they are a continuing drag on efficiency for 43% of providers. Burdened by limited resources, these revenue cycle teams are more likely to make avoidable errors during claim submission—a problem that is affecting the four in ten providers who say they have limited resources to cross-check claims for errors. Riggins suggests that healthcare organizations look to technology to close the claims gap: “We had hoped to see a decrease in claim denials from our previous survey, but it's clear these significant challenges are continuing, adding immense pressure on providers to improve their revenue cycle management processes. This growing crisis is a sign that traditional approaches are no longer enough, and providers should adopt more proactive strategies and the latest technology to navigate this volatility.” Top reasons for healthcare claim denials Here are the top three claim denial reasons and how automation and AI can solve them: 1. Missing or inaccurate claims data Missing or inaccurate claims data is the number one operational challenge responsible for the increase in medical billing claim denials – among the top three challenges for 46% of respondents in the State of Claims 2024 survey. Submitting clean claims relies on getting data right the first time. It calls for speed and efficiency, which is impossible with slow, error-prone manual systems. Yet almost half of the respondents say their organizations are reviewing claims manually. While 54% of respondents believe their technology is sufficient to meet claims management demands, increasing errors and rising denials tell a different story. Revenue cycle leaders who embrace automation in their claims submission and denial prevention strategy set themselves up for smoother operations and a boost to the bottom line. Without the right automation to increase the speed and accuracy of claim submissions, valuable staff time and effort are wasted on manually processing error-prone claims, increasing the likelihood of denial. The lack of automation also places unnecessary strain on staff, diverting their attention from more complex claims issues. 2. Prior authorizations Claim denials often stem from poor communication between payer and provider systems, with the prior authorization process as a prime example. The process requires providers to seek agreement from the payer to cover a service or item before it is administered to the patient. Failure to do so results in the claim for that treatment being denied. Unfortunately, obtaining prior authorizations is not always straightforward; sometimes, the patient's treatment must begin before the authorization process is concluded. Other times, the authorization only covers certain aspects of the treatment. Not only is the prior authorization process complex, but it is also costly, laborious, and time-consuming to navigate successfully. According to the 2023 AMA Prior Authorization Physician Survey, physicians and their staff spend 12 hours per week completing prior authorizations, with almost all reporting physician burnout as a result. Providers must stay on top of frequent changes to payer policies, and staff must use multiple payer portals to track authorization requests. Unsurprisingly, authorizations are among the top three claim denial reasons for 36% of respondents in the State of Claims survey. As with any challenge involving digital systems “talking” to one another, authorizations are a great use case for automation. Automation can be used to check payer policy changes, alert staff when prior authorization is needed, gather relevant documentation, and review authorization requests for accuracy. This significantly reduces the burden on staff and minimizes the risk of claims being submitted without the necessary authorizations in place. Experian Health's Prior Authorizations technology automates authorization inquiries and checks requirements in real time. It uses AI to help users find and access the appropriate payer portal to speed up the authorization workflow. Users will have confidence that they're looking at the same account information and policy details as the payer, which means lengthy negotiations can be avoided. Staff also get accurate status updates on pending and denied submissions so they can take appropriate action and maximize reimbursement. 3. Inaccurate or incomplete patient data Even the slightest mistake or mismatch in a patient's name, address or insurance details can result in a denial, leading to payment delays and extra work for the staff. These denials are particularly frustrating because they should be avoidable. Automation can be used to pre-fill the patient's information before they arrive to avoid the errors that occur with manual input. This has the added benefit of accelerating registration. These solutions can also check for duplicate charges, missing fields and coding inaccuracies. For example, Claim Scrubber helps providers prepare error-free claims for processing by reviewing each line of the claim before it's submitted. ClaimSource® helps providers manage the entire claims cycle by creating custom work queues and automating claims processing to ensure that claims are clean the first time. Implementing technology to prevent claim denials The report details some of the strategies providers are using to try to reduce denials. These include upgrading existing claims process technology, automating or expanding patient portal claims reviews, and automating tracking of payer policy changes. More than half are motivated to adopt new technology to reduce manual input. This is exactly what Denial Workflow Manager is designed to do. It enables providers to track claim status and appeals and quickly identify those that need to be followed up on. It eliminates the need for manual review, while analysis and reporting give staff insights into the root causes of denials to optimize performance. This solution can be integrated with tools like Enhanced Claim Status, which sends automatic status requests based on the type of claim and specific payer timeframes. It generates accurate adjudication reports within 24-72 hours to accelerate the revenue cycle. The output is viewable in ClaimSource to streamline workflows and manage the claims process in a single online application. Automation and digital technology are also valuable counterweights to the shortage of qualified staff. While staffing shortages aren't as high on the list of concerns as in previous years, they remain a stubborn problem. By reducing the need for manual input, claims management can be accelerated while freeing staff to focus their attention where it matters most. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more AI solutions for reducing claim denials Healthcare organizations can get more bang for their buck from automation by integrating these solutions alongside AI. Interestingly, the survey suggests that providers have mixed feelings towards AI: 35% of providers say they want solutions that leverage more AI and machine learning, yet only 8% are actually using them. Current ClaimSource users might consider AI Advantage™, which uses AI and automation to generate real-time insights for a proactive approach to denial management. It helps providers combat claim denials from two angles: AI Advantage – Predictive Denials uses AI to identify undocumented payer adjudication rules that result in new denials. It identifies claims with a high likelihood of denial based on an organization's historical payment data and allows them to intervene before claim submission. AI Advantage – Denial Triage comes into play if a claim has been denied. This component uses advanced algorithms to identify and intelligently segment denials based on potential value so that organizations can focus on resubmissions that most impact their bottom line. Doing so removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials. This solution complements existing claims management workflows to help providers expedite claims processing, reduce denials, and maximize revenue. Another AI-powered solution helps prevent denials on the front end: Patient Access Curator allows patient access teams to capture multiple data points in seconds. This solution solves the “bad data” problem, using AI and robotic process automation to run checks for eligibility, coordination of benefits, Medicare Beneficiary Identifier, demographics and coverage discovery with a single click. The financial impact of denials and the ROI of technology Another paradoxical finding in the report is that while 47% of respondents see having AI technology as a competitive advantage, less than half say they'd be up for fully replacing their existing claims processing technology, even if presented with compelling ROI projections. Automation and AI can meaningfully impact the claims metrics that keep revenue cycle leaders awake at night – denial rates and clean claim rates being the top two. Patients also want to see improved performance when it comes to reducing denials. If healthcare organizations cannot offer a reliable, error-free system, they risk losing patients' trust and loyalty. Providers who demonstrate a well-managed claims system with swift and accurate results will inspire confidence and improve patient engagement. It's essential to assess how existing solutions perform against these metrics and implement upgraded solutions to deliver a more substantial ROI. AI and automation in practice How are Experian Health's clients using AI and automation to reduce claim denials? Here are a few examples: In only six months of adopting AI Advantage for claims processing and reducing claims denial, Schneck Medical Center saw denials fall by an average of 4.6% each month. In addition, the time needed to correct claims dropped from 15 to less than five minutes. The ambulatory clinic Summit Medical Group Oregon implemented Experian Health's claims management solutions, including Enhanced Claim Status and Claim Scrubber, to improve its registration and coding processes. These two solutions helped the team submit cleaner claims, resulting in a decrease in denials. As a result, the company now maintains a 92% primary clean claims rate. Another compelling example of the positive impact of technology on healthcare claims management is IU Health's experience with the all-in-one claim cycle management platform ClaimSource. With ClaimSource, IU Health managed the transmission of $632 million in claims in five days and processed $1.1 billion of claims backlog. Clients who have implemented Experian Health's Patient Access Curator have saved over $1 billion in denied claims, significantly boosting their bottom lines. Experian Health ranked #1 in Best In KLAS for our ClaimSource® claims management system – for the second consecutive year.  Learn more Enhancing revenue cycles by addressing claim denial reasons By pinpointing the most common health insurance claim denial reasons and adopting automation and AI-driven solutions, providers can increase the first-pass clean claim rate, ramp up the likelihood of reimbursement, and reduce the overhead of reworking and resubmitting claims. Inevitably, hospitals will witness a surge in their financial performance. Contact us today to learn how data-driven claims management technology can help your organization reduce denied claims in healthcare and increase ROI. Improve claims management Contact us

Claim denials are a well-documented challenge for healthcare organizations. Denied claims take much longer to pay out than first-time claims, if they get paid at all. Each one means additional hours of rework and follow-up, pulling in extra resources as staff review payer policies and figure out what went wrong. It's time-consuming and costly. Beyond dollars and paperwork, denials affect patient care as uncertainty about payments leads to delays in treatment or unexpected out-of-pocket costs. But how do healthcare leaders feel about the state of claims management today? How are they tackling the administrative burden? Is there any light at the end of the denials tunnel?   Experian Health surveyed 210 healthcare revenue cycle leaders to find out. The 2024 State of Claims report breaks down the survey findings, including insights into how automated claims technology is being used (or not!) to optimize the claims process and bring in more revenue. What is the current denial rate for healthcare claims? 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of rework and lost revenue that providers were counting on. In 2009, claims processing accounted for around $210 billion in “wasted” healthcare dollars in the US. A decade later, the bill had climbed to $265 billion. Industry reports—including Experian Health's State of Claims series—repeatedly observed a rise in denial rates. Today, 73% of providers agree that claim denials are increasing, while 67% feel it's taking longer to get paid. Providers constantly worry about who will pay – and when. What are the most common reasons for healthcare claim denials? According to the State of Claim survey respondents, the top three reasons for denials are missing or inaccurate data, authorizations, inaccurate or incomplete patient info. In short? The problem is bad data. Given how much information has to be processed and organized to fill out a single claim, this isn't surprising. From patient information to changing payer rules, the sheer volume of data points to be collated creates too many opportunities for errors and omissions. On top of that, the rules are always changing. More than three-quarters of providers say payer policy changes are occurring more frequently than in previous years, making it increasingly difficult to keep up. Other challenges, such as coding errors, staff shortages, missing coverage and late submissions still play a role, but it's clear that solving the data problem could make a meaningful dent in the denials problem. Read the blog: How data and analytics in healthcare can maximize revenue Could automation improve claim denial statistics? To help end the cycle of denials, more healthcare providers are turning to claims management software to resolve or prevent the snags that interfere with claims processing and billing workflows and boost claim success rates. That said, around half of providers still review claims manually. Despite the proven benefits of integrated workflows and automation, the drive to implement new technology during the pandemic seems to have lost momentum: the number of providers currently using some form of automation and/or artificial intelligence (AI) has dropped from 62% in 2022 to 31% in 2024. Could this be down to a lack of comfort with how new technologies work? Only 28% feel confident in their understanding of automation, machine learning and AI, compared to 68% in 2022. For those who are curious but cautious, here are a few ways claims automation can help improve claim denial statistics: Connect the entire claims process end-to-end: Using an automated, scalable claims management system like ClaimSource® helps providers manage the entire claims cycle in a single application. From importing claims files for faster processing to automatically formatting and submitting claims to payers, it simplifies the claims editing and submission process to boost productivity. Submit more accurate claims: 65% of survey respondents say submitting clean claims is more challenging now than before the pandemic. There's a strong case, then, for using an automated claim scrubbing tool to reduce errors. Claim Scrubber reviews pre-billed claims line by line so errors are caught and corrected before being submitted to the payer, resulting in fewer undercharges and denials and better use of staff time. Improve cash flow: Automating claim status monitoring is one way to accelerate claims processing and time to payment. Enhanced Claim Status eliminates manual follow-up so staff can process pended, returned-to-provider, denied, or zero-pay transactions as quickly as possible. Eliminate manual processes: While there are some tasks that genuinely need a human touch, too much staff time is wasted on repetitive, process-driven activities that would be better handled through automation. Denials Workflow Manager automates the denial process to eliminate the need for manual reviews. It helps staff identify denied claims that can be resubmitted and tracks the root causes of denials to identify trends and improve performance. It also integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so staff can view claim and denial information on a single screen. Experian Health was client-rated #1 by Black Book™ '24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Improving claim denial statistics with AI While automation speeds up the denials workflow by taking care of data entry, AI can look at that data and recommend next steps. Current ClaimSource users can now level up their entire claims management system with AI AdvantageTM, which interprets historical claims data and payer behavior to predict and prevent denials. The video below gives a handy walk-through of how AI Advantage's two offerings, Predict Denials and Denial Triage, can help providers respond to the growing challenge of denials: As the survey shows, there's a growing need for easy-to-implement solutions to the denials challenge. While progress has been made, the findings suggest there's still room to use automation and AI more to prevent denials and level the playing field with payers. Download Experian Health's 2024 State of Claims report for an inside look at the latest claim denial statistics and industry attitudes to claims and denials management. 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Despite increased access to claims management technology, claims denials are still on the rise in 2024. Contributing factors include growing healthcare costs, stricter payer reimbursement policies, and claims processing errors. Providers are seeing an uptick in nonpayment, plus an added burden on administrative staff, disrupted patient care, and hits to the bottom line. Experian Health surveyed over 200 healthcare professionals, primarily in executive or management roles, to better understand the current state of claims. The findings of the State of Claims 2024 report break down the latest health insurance claim denial statistics, reasons for denials, and providers' concerns about reimbursement. Rising healthcare costs: who will foot the bill? The U.S. healthcare system is the most expensive in the world, and costs continue to rise. In 2022, healthcare spending reached $4.5 trillion, a threefold increase from $1.4 trillion in 2000. In 2023, costs rose 7.5% to $4.8 trillion. Paying for healthcare is becoming more and more out of reach for patients and causing great concern. Over three-quarters (77%) of providers worry patients will skip out on their medical bills. Payer reimbursement challenges are also weighing heavily on healthcare leaders' minds. More than 75% are worried about nonpayment due to ever-evolving payer policy changes. They also have concerns about the pre-authorization struggles that have continued since 2022, as reported in the State of Claims 2022 survey. Hospitals are particularly feeling the financial pinch of operating within such an expensive environment and face uncertainties about meeting financial obligations on top of other major post-pandemic challenges like staff shortages. The impact of claims denials Providers continue to see claims being denied in greater numbers. In 2022, 42% of respondents said denials are increasing. The number jumped to 77% in 2024. Similarly, the time it takes to be reimbursed is increasing, per 67% of respondents. That number was 51% in 2022. In 2024, 84% of healthcare organizations will make reducing denied claims a top priority. The Journal of Managed Care & Specialty Pharmacy reports that the burden of denied claims totals around $260 billion annually. The impact of claim denials is far-reaching, affecting the patient experience and revenue cycles. Struggles with claims also burden staff and drain resources, contributing to even more losses. The growing challenge of data collection, verification and authorization Successful claims processing depends on accuracy. However, achieving accuracy in data collection, verification, and authorization processes remains a continued challenge for claims management teams. Nearly half of respondents (46%) in the State of Claims 2024 report identified missing or inaccurate information as the primary cause for denial. Inaccurate or missing data also creates extra steps in claims processing, resulting in the need for secondary checks and “wasted” healthcare dollars. Survey respondents reported using multiple solutions to collect all the necessary patient data for claims, with some using as many as four different products. Leveling the playing field in claims management with technology Staying on top of reimbursement requirements and processes is complex, resource-demanding and time-consuming. Inaccuracies commonplace with manual processing exacerbate issues and further extend processing and reimbursement times. However, automation and AI technology have proven effective at reducing claims denials and the burden of manual processing. “Adding AI in claims processing cuts down denials significantly,” Tom Bonner, Principal Product Manager at Experian Health, explains. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction—AI is the tool hospitals need for better healthcare claims denial prevention and management.” During the pandemic, providers embraced new technology to meet immediate needs; however, that momentum slowed in recent years. In 2022, survey data revealed that 62% of providers were using some form of automation and AI technology. Yet, in 2024, only 31% said they used this type of technology. Here's how claims automation can help healthcare organizations improve claims success rates: Manage the entire claims process: Using an automated, scalable claims management system, like ClaimSource®, helps reduce denials and increase revenue. Providers can manage their entire claims cycle in a single application and ensure claims are clean before submission. Submit more accurate claims: An automated claims submission tool, like ClaimScrubber, helps identify errors that typically result in denials or underpayments before submission. This results in quicker payments, less time chasing aged accounts receivables, and improved cash flow. Eliminate manual processes: Providers that use Denials Workflow Manager can target claims that need attention immediately, managing denials more effectively and increasing reimbursements significantly. Improve cash flow: Enhanced Claim Status helps providers take an early-and-often approach to monitoring claim status in the adjudication process. It eliminates manual follow-up tasks, allowing providers to respond early and accurately to pended, returned-to-provider, denied or zero-pay transactions. Prevent denials: Experian Health's AI Advantage™, an AI-driven platform, uses an organization's own historical claims data, plus Experian Health's sophisticated knowledge of payer rules, to continuously learn and adapt to an ever-changing payer policy landscape. This technology helps providers better predict and prevent claims denials, focus on high-priority claims, and boost overall revenue. Adaptation of technology is likely on the rise with 45% of healthcare leaders planning to invest in automation in the next six months. Over the next year, these investments could pay off if claims denials start to decrease as a result, prompting more healthcare organizations to boost investments in claims management technology. Download the State of Claims 2024 report to get the latest health insurance claim denial statistics, or contact us to learn how Experian Health can help with better claims management. Get the report Claims management solutions