Tag: claim denials

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

Healthcare claim denials persist as a significant challenge, impacting the efficiency, affordability and timeliness of healthcare delivery and hospitals' financial well-being. They contribute a substantial portion of the staggering $265 billion annual in waste attributed to administrative complexities. On average, hospitals face a yearly loss of $5 million due to healthcare claim denials, amounting to 5% of their net patient revenue, according to the Journal of AHIMA. Yet it appears that the rise in claim denial rates continues unabated. Experian Health's State of Claims 2022 report revealed that 30% of respondents experience medical claims being denied in 10-15% of cases, and 42% confirm an increasing trend in denial rates from one year to the next. There is no question that the claims denial process is ripe for innovation, and that's where reducing healthcare claim denials with artificial intelligence (AI) comes in. Like many other sectors, healthcare providers are slowly but increasingly turning to automation and AI for more accurate data and better insights. The Experian Health survey shows over one-half of healthcare providers turn to AI-driven healthcare claims management software to reduce claim denials. "Adding AI in claims processing cuts 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." The current challenges in claims management High patient volumes and complex payer policies Experian Health's 2022 State of Claims survey revealed that reducing denials was a top priority for almost three-quarters of healthcare leaders. Why? High patient volumes mean there are more claims to process, and changing payer policies and insurance coverage compound an already overwhelming problem. An Sg2 report predicts that patient volume issues will continue over the next decade, with inpatient hospital volumes growing by 2%. This rise in patient numbers will require more data for claims management processing. Hospitals, often short-staffed, will have to allocate more resources to ensure claim approval and increase efforts to address claims denial. In addition to managing increasing patient volumes, keeping track of changing payer coverage and requirements has always been challenging for providers. The inconsistency of these payer rules and communication problems exacerbate the situation. Healthcare providers may need efficient solutions to keep up with these rule changes or allocate more time and resources to addressing and revising claims. Labor shortages and financial pressures According to a data brief from the American Hospital Association, the increasing rate of clinician burnout, the enduring effects of COVID-19, and ongoing strains on the healthcare workforce are compelling hospitals to recognize and tackle chronic labor shortages. Notably, 80% of healthcare leaders acknowledge that chronic staffing shortages present significant risks for their organizations. Increasing denial rates is one way these risks manifest. As the State of Claims 2022 report confirms, 30% of respondents mentioned staffing shortages significantly contribute to healthcare claim denials. Additionally, Experian Health's recent survey, Short Staffed for the Long-Term, which investigated the impact of healthcare staffing shortages, found that 70% of respondents facing staff shortages also experienced increasing denial rates. Labor shortages mean fewer hands on deck to deal with the claims processing workload, while financial pressures on hospitals mean the stakes are higher than ever to solve the problem of claim denials. Limitations and costs of manual claims processes Health payers deny hospital systems about $260 billion worth of inpatient claims annually. According to Experian Health's survey, manual processing and a lack of automation are the primary reasons for these medical claim denials. The State of Claims 2022 report found that 61% of respondents do not automate claims submission and denial prevention processes, leaving them to rely on manually processing claims. However, manual claims management tools simply cannot keep up with the complexities and data-intensive nature of claims processing. When claims processes are handled manually, healthcare workers are burdened with cumbersome tasks that could have been automated, there is a higher risk of errors that lead to claims denial, and there'll be more need to dedicate extra time and effort to appeal denied claims. These intensive steps necessary for manual claims processing drain staff resources and create opportunities for money and time waste that are eventually detrimental to the hospital's financial circumstances. How AI and automation address healthcare claim denials Automation and AI can ease the pressure by processing more claims in less time. They give providers better insights into their claims and denial data so they can make evidence-based operational improvements. AI tools achieve this by using machine learning and natural language processing (NLP) to identify and learn from data patterns and synthesize huge data swathes to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation in claims processing can complete rules-based, repetitive tasks with incredible speed and reliability that a person might not achieve. By using automation and AI in claims processing, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Tom Bonner says, "AI in healthcare claims processing maximizes the benefits of automation for better claims processing, better customer experiences and a better bottom line for healthcare providers." However, the pace of AI adoption is somewhat slower in healthcare due to legacy data management systems and data silos. As efforts to improve interoperability progress, providers will have more opportunities to deploy AI-based technology. This prediction is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for reducing claim denials with AI to help maximize reimbursements. Key benefits of AI in healthcare claims management Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software exponentially benefits claims management through its predictive, accuracy, and error-reduction capabilities. Predictive Analytics and Pattern Recognition: The benefits of AI in healthcare claims processing lie in the ability of AI-driven solutions to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can analyze patterns in historical claims data to predict future volumes and costs, so providers can plan accordingly without simply guessing at what’s to come. Error Reduction and Clean Claim Submissions: AI can also assist in identifying inaccurate claims and improve claims processing accuracy to ensure clean claim submission and efficient revenue cycle management. Case studies and real-world applications AI and automation in claims processing are helping healthcare providers overcome the challenges contributing to increasing claim denial rates. Experian Health's AI-driven and automation solutions, like AI Advantage™, enable clients to benefit from the full potential of AI and automation to minimize claim denials. How Community Medical Centers uses AI Advantage to predict and prevent healthcare claim denials Community Medical Centers (CMC), a non-profit health system in California, uses Experian Health's new solution, AI Advantage, which uses AI to prevent and reduce claim denials. Eric Eckhart, Director of Patient Financial Services, says they became early adopters to help staff keep up with the increasing rate of denials, which could no longer be managed through overtime alone. "We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with the results we're seeing now." AI Advantage reviews claims before they are submitted and alerts staff to any likely to be denied based on patterns in the organization's historical payment data and previous payer adjudication decisions. CMC finds this particularly useful for addressing two of the most common types of denials: those denied due to lack of prior authorization and those denied because the service is not covered. Billers need up-to-date knowledge of which services will and will not be covered, which is challenging with high staff turnover. AI Advantage eases the pressure by automatically detecting changes in how payers handle claims and flagging those at risk of denial so staff can intervene. This reduces the number of denials while facilitating more efficient use of staff time. Eckhart says that within six months of using AI Advantage, they saw 'missing prior authorization' denials decrease by 22% and 'service not covered' denials decrease by 18% without additional hires. Overall, he estimates that AI Advantage has helped his team save more than 30 hours a month in collector time: "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." How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks Providence Health is a prominent health system with 56 hospitals and over 1,000 physician clinics, serving an annual patient volume of over 28 million. This magnitude of patient volume created greater issues with slow and manual payer eligibility processes and increased eligibility denials. Furthermore, in response to Epic's growing payer plan table, Providence Health sought an effective solution to merge and organize data on insurance plans, contracts, and reimbursement details and automate eligibility tracking within the system. Their search led them to Experian Health's Insurance Eligibility Verification solution. According to Emily Brown, Director of Operation Excellence, "Our search for a solution that seamlessly integrates with Epic led us to choose Experian as our preferred vendor, given their proven track record of working with Epic." Providence Health implemented Experian's Eligibility solution, including a Bad Plan Code Detection tool to catch coding errors before submission. The solution also allowed them to stay connected to over 900 payers and provide backup connectivity to over 300 additional payers for uninterrupted service. The solution's automated work queues also helped staff work more efficiently. Providence reduced denial rates, saving $18 million in potential denials in 5 months of implementing Experian's Eligibility solution. The tool also helped them find $30 million in coverage annually while reducing staff workload. How Schneck Medical Center prevents and triages denials with AI Advantage™ Schneck Medical Center delivers care to four counties in Indiana, supported by a team of over 1,000 employees, 125 volunteers, and close to 200 physicians. According to Skylar Earley, Director of Patient Financial Services, "The challenge we (Schneck Medical Center) sought to overcome by leveraging AI Advantage at our organization was just gaining more insight into how denials originate and what actions we can take to prevent those from happening." Schneck Medical Center collaborated with Experian Health to implement: AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. They aimed to use these tools to identify claims that were more likely to be denied so that the appropriate personnel could address them and clean them before sending them to payers. They also wanted to be able to identify and prioritize denials with the potential for revenue reimbursement that will impact their bottom lines. AI Advantage™ — Predictive Denials enabled team members to make informed and timely decisions before submitting claims. In the first six months of using the tool, Schneck achieved a 4.6% average monthly decrease in denials. The time spent on denials decreased by 4x, and flagged claims were resolved in 3–5 minutes rather than the previous 12–15 minutes per correction. With AI Advantage — Denial Triage, billers were able to redirect their effort on denials more likely to be reimbursed. This prioritization enables them to avoid wasting time on high-dollar claims that are unlikely to be paid. "We had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages," says Skylar Earley, Director of Patient Financial Services Steps to implementing AI in claims management AI Advantage works in two stages in claims management, reducing claims denial and addressing denied claims to prioritize those with the best value for reimbursement. Stage One: Predictive Denials Stage one is Predictive Denials, which uses machine learning to look for patterns in payer adjudications and identify undocumented rules that could result in new denials. As demonstrated by CMC and Schneck Medical Center, this helps providers prevent denials before they occur. Stage Two: Denial Triage Stage two is Denial Triage, which comes into play when a claim has been denied. This component uses advanced algorithms to identify and segment denials based on their potential value so staff can focus on reworking the denials that will impact their bottom line. Enhancing revenue cycle management with AI Embracing integrated workflows uncovers novel applications for reducing healthcare claim denials with AI and automation. AI Advantage seamlessly works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. These integrations amplify the benefits of each tool, giving healthcare providers better insights into their claims and denial data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Key differentiators In addition to its AI solutions, Experian Health offers solutions that automate claims processing to facilitate claims management and increase efficiency. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software generates accurate adjudication reports within 24 to 72 hours to speed up reimbursement. ClaimSource ranked #1 in Best in KLAS 2024, for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. Another Experian Health solution, Enhanced Claim Status, improves cash flow by responding early and accurately to denied transactions. This solution gives healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim was denied Speeds up the denials process Automates manual claims follow-ups Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims Denials Workflow Manager integrates with the Enhanced Claim Status solution to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. Using AI and automated solutions to prevent healthcare claim denials There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex, but human error plays a large part in missed opportunities and lost revenue. The revenue cycle becomes seamless with AI and automation in healthcare claims management. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI and automation-driven claims management software offers healthcare organizations a way to achieve these goals. Contact Experian Health today to prevent healthcare claim denials and improve your claims management process with AI Advantage and other denial management solutions.

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.

“We are really happy with Experian. It takes away duplication of efforts and allows us to see the bigger picture. The eligibility solution works well for our team and patients.” —Emily Brown, Director of Operation Excellence at Providence Health  Challenge Providence Health is a leading health system comprising of 56 hospitals and over 1,000 physician clinics. With an annual patient volume of over 28 million, Providence strives to prioritize the well-being of their patients by providing convenient, accessible, and affordable medical services.   Because of high patient volumes, they faced issues with slow payer eligibility processes and increased eligibility denials, which meant their staff spent a lot of valuable time verifying eligibility manually.   Additionally, as Epic's payer plan table expanded, Providence Health needed an efficient way to consolidate and align the data pertaining to insurance plans, contracts, and reimbursement details. In order to streamline the process and keep their staff within the system, Providence Health sought to automate eligibility tracking.  Solution Providence Health implemented Eligibility Verification and leveraged the Bad Plan Code Detection tool, which identifies coding errors before they're submitted to payers. With this solution, the system immediately alerts users when an incorrect plan code is flagged, allowing users to fix any issues quickly and avoid costly claim rework. Additionally, integration with Epic facilitated seamless 1:1 plan mapping, and automated the creation of new coverage records in Epic based on responses received. This streamlined the process, eliminating guesswork for staff and ensuring accurate plan selection. Emily Brown, Director of Operation Excellence says, “Our search for a solution that seamlessly integrates with Epic led us to choose Experian Health as our preferred vendor, given their proven track record of working with Epic.” By working with Experian Health, Providence has uninterrupted service and connections to over 900 payers, with backup connectivity to 300 additional payers. Providence staff can utilize automated work queues fueled by response data and custom alerts, which allows them to work more efficiently.   Outcome Thanks to Eligibility Verification, Providence Health achieved the following results:  Found an average of $30 million in coverage annually   Saved $18 million due to decreased denial rates within five months  By automating eligibility checks for high patient volumes, Providence Health boosted patient satisfaction while significantly reducing staff workload. Partnering with Experian Health allowed them to identify an increased amount of active eligibility, ensuring accurate reimbursement and avoiding claim denials. Automation also eliminated time-consuming tasks, allowing staff to focus on providing better patient care.   “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.”   - Providence Health Patient  Learn more about how Eligibility Verification helps healthcare organizations access real-time insurance coverage data, improve reimbursement rates and avoid claim denials.  

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.

“As the IU Health Revenue Cycle team rallied to respond to the claims processing disruption, we were uniquely positioned with our long-time Experian partnership to quickly re-institute critical claims routines and restore a significant volume of claims transmissions.  This would not have been possible without Experian's nimble and comprehensive approach, immediately applying talented and committed resources that leveraged existing Experian platform infrastructure.” – Bryan Daniels, Vice President Revenue Cycle Solutions, IU Health Challenge Indiana University Health (IU Health) is the largest network of physicians in Indiana comprised of over 38,000 team members and 2,717 available beds. Based in Indianapolis, Indiana, the organization has dozens of facilities statewide and is on a mission to make the state one of the healthiest in the nation. In February 2024, IU Health found itself impacted by the cybersecurity incident so many providers across the country abruptly faced. They were unable to send claims to insurance companies and their revenue cycle operations came to screeching halt. Knowing they needed a trusted solution fast, the revenue cycle leadership team asked Experian Health if they could help. Solution Conversations advanced quickly and the Experian Health team was able to implement its Best in KLAS ClaimSource® platform within a week. ClaimSource is an innovative claims management solution designed for scalability and improves revenue streams by minimizing denials. By using automation, it boosts operational efficiency by prioritizing claims, payments, and denials, allowing users to tackle high-impact accounts promptly. Outcome Thanks to ClaimSource, IU Health achieved the following results: Accelerated $632 million in claims transmissions in the first five days of business. Processed $1.1B of claims backlog by March 27.  “We value our longstanding partnership with IU Health and it's very rewarding that we were able to help in a very critical situation,” said Jason Considine, Experian Health's Chief Commercial Officer. “We know IU Health places the utmost importance on patient care, and being an important part of our client's solution to deliver on their service commitment is reflective of our service commitment to simplify healthcare.” Learn more about how ClaimSource can help your healthcare organization accelerate cash flow, reduce denials and optimize efficiency.

Healthcare leaders often zero in on how uninsured rates affect their bottom line. But another patient group presents a quieter financial dilemma for providers: those with multiple active health plans. In these cases, it's important to ensure each plan pays the right amount – in the right order. Should any confusion arise, providers may end up with their claims being denied, resulting in underpayments. This is where the coordination of benefits (COB) process comes in. What is coordination of benefits (COB) and why is it important? When a patient is covered by more than one plan, the “coordination of benefits” process kicks in to help health plans figure out their respective payment responsibilities. With patients often having multiple insurance policies, ensuring that each policy pays its share is vital. The purpose of coordination of benefits is to prevent overpayment or duplication of benefits, ensuring that the total benefits paid do not exceed the actual cost of the service received. Integrating a digital COB solution within registration and scheduling workflows can help providers ensure they bill primary and secondary payers correctly, preventing unnecessary claim denials. Challenges of coordination of benefits  Coordination of Benefits is a pivotal aspect of RCM, but it's not without its hurdles. Here's a look at the complexities that often arise:  Overlapping Policies: Determining which policy pays first can be confusing. Patients with dual coverage might not always be aware of the hierarchy, leading to billing complications. And many legacy systems only select the primary, without consideration for secondary or tertiary. And regional plans add another layer of complexity.  Claim Denials: Incorrect coordination of benefits can lead to claim denials or overpayments. This not only affects revenue but also strains the patient-provider relationship when patients are billed incorrectly.  Administrative Burden: Manual COB verification is time-consuming and prone to errors. Staff often spend hours cross-referencing policies, which could be better spent on patient care.  Coordination of benefits: the dream vs. reality In an ideal world, patients would register for care weeks ahead of their scheduled treatment. During the registration process, they would inform the provider of all their active insurance coverage, with correct and complete details close to hand. No plan would go unmentioned, and no policy number misplaced. Registration staff would quickly enter the information into their EMR without error, so coverage could be verified in real-time. The reality is far different. Recent findings show that 65% of consumers struggle to understand what their health insurance covers. They do not carry copies of their insurance cards. They may not be aware that they are covered under a relative's health plan. Patient access teams are under-staffed and over-stretched, with little time to ask guiding questions that would uncover additional insurance. Coordination of benefits efforts should start as soon as it becomes apparent that a patient has active coverage under multiple plans. Unfortunately, the messy reality of coverage discovery and patient registration means patients and providers are left in the dark until a claim is denied. The payer rejects the claim for a COB-related reason, leaving billers with no clue how to resolve it. The problem gets worse from there. Automating coordination of benefits for faster, cleaner claims As with all aspects of healthcare billing, there are many complex rules and regulations governing COB transactions. Under HIPAA, health plans and payers (including Medicare and Medicaid) must coordinate benefits for each patient and determine the primary and secondary payers. Tracking this manually is extremely challenging for providers: using the information provided by the patient (which may or may not be accurate), staff would contact each payer by phone or email to verify coverage. They would then review the COB rules and guidelines for each health plan to determine the primary payer and follow specific rules for billing secondary payers. It's no wonder that COB transactions are now among the most automated administrative tasks. Automating coordination of benefits not only saves staff time, but also increases the chances of finding all active coverage, collating complete insurance profiles for the patient, and making an accurate primacy determination. Digital systems also make it easier for providers and payers to communicate with one another, facilitating smoother dispute resolution and regulatory compliance. Patient Access Curator brings real-time COB to EH clients In late 2023, Experian Health acquired Wave HDC, bringing clients a new and unrivalled package of real-time coverage and benefits solutions based on AI-powered data curation. This new solution, Patient Access Curator, helps healthcare billing teams prevent claim denials in seconds through real-time data analysis. This includes COB curation, which automatically analyzes payer responses to identify hidden cues that staff cannot see. If other insurance is identified, the tool alerts the user and triggers additional queries to verify active coverage and build a complete insurance profile for the patient. Each policy is then analyzed further to determine the patient's primary, secondary and tertiary coverage, reliably sifting out any non-billable coverage. Since 2020, the technology powering Patient Access Curator has prevented denials amounting to more than $1 billion. Integrating coordination of benefits automation yields savings throughout the revenue cycle Integrating COB automation with other RCM tools, such as coverage discovery and eligibility verification, means providers can prevent and manage denials in a single workflow. Doing this during patient registration allows teams to resolve issues in the early stages of the revenue cycle, rather than wait to deal with them once claims are denied. While catching errors on the front-end results in faster patient registration and clean claims first time, the tool adds value later in the revenue cycle, too. Streamlining the correction process prevents revenue loss and reduces the need for manual intervention. Here's how these use cases look in practice: In one multistate practice, the technology automated COB curation with insurance verification during patient registration. This enabled primary coverage corrections for 12% of patient registrations and identified undocumented Medicare and Medicaid coverages for 6% of registrations. Left unchecked, these omissions would have resulted in denials, delays, and missed revenue opportunities. The technology was deployed in the denials workflow at a large health system, where it identified COB corrections for 92% of all COB denials. Of these, 60% were immediately refiled to the correct primary payer, minimizing delays in revenue recovery. In the remaining claims, the tool found evidence of inaccurate or outdated third-party liability records within payer claim adjudication systems. Providers urgently need revenue cycle processes to be as efficient and reliable as possible – especially when dealing with patients with multiple, complex health plans. A powerful denial prevention solution that slots neatly into the registration workflow means they can maximize revenue with minimal human intervention. And with accurate results delivered in seconds, Patient Access Curator could be just what the doctor ordered. Get in touch today to find out more about coordination of benefits automation and discuss other ways to increase efficiency on the front-end of the revenue cycle, using Patient Access Curator.