Tag: claims management

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.

Claim denials are costly to correct and resubmit. They impede revenue flow, slow down patient care delivery, contribute to poor patient experience and satisfaction, increase administrative workload and take up limited staff time and resources. While they're avoidable, Experian Health's State of Claims 2022 report shows that 30% of respondents say denials are increasing between 10-15% year over year, which costs health systems billions of dollars. Moreover, rebilling payers often proves fruitless. Despite taking up resources and staff time and productivity and slowing down healthcare delivery, reworked and resubmitted claims denials often face repeated rejection. A KFF brief on claims denial noted that even though it's uncommon for consumers to resubmit denied claims, insurers usually stick to their original decision when resubmissions occur. Unsurprisingly, preventing claims denial and streamlining the claims management process has become a pressing need for revenue cycle leaders. The report also revealed that 70% of respondents consider claims management and reducing denials as top priorities. However, the reality of a drop in claim denial rates becomes tangible only when healthcare organizations start to automate claims processes. Claim Scrubber sets the standard as a software solution that effectively reduces denial rates, by ensuring that providers submit clean claims from the start. What is Claim Scrubber? Claim Scrubber is an automated software solution that helps healthcare providers identify errors that may lead to incorrect billing and claims denials and submit clean, thorough and accurate claims every time. It reduces undercharges and denials, ensures timely billing and payments, improves staff time and productivity and increases cash flow and bottom lines. This tool is built to seamlessly complement Experian Health's other claims processing solutions, including ClaimSource® and Denial Workflow Manager. By adopting these solutions, healthcare organizations can enjoy the full range of benefits in their claims processing and management experience while benefiting from timely, uninterrupted cash flow and higher revenue. How does Claim Scrubber work? Claim Scrubber is designed to consistently and reliably help healthcare staff produce clean and accurate claims that are more likely to be approved by payers. Here's how: Claim Scrubber meticulously analyzes each line of every pre-claim to ensure accurate coding and information before submission to the claims clearinghouse. After completing the analysis, Claim Scrubber provides general and payer-relevant edits that pinpoint incorrect code combinations or other issues that could lead to claim denial. These edits are stored within the Claim Scrubber portal and can be conveniently accessed by users from their PMS and HIS. Claim Scrubber details reasons for flagging a claim so users can make appropriate corrections before submission. Claim Scrubber enables users to make edits in alignment with payer policies by using Experian Health's comprehensive database of commercial payer policies and content. Claim Scrubber also identifies when the billed amount is less than the payer-allowed amount, helping health systems catch and correct undercharges. Claim Scrubber cleans claims, making them error-free by working with the latest and most up-to-date data. Claim Scrubber is fully functional in batch mode. Claim Scrubber operates on a secure VPN connectivity feature to ensure secure and rapid responses for real-time integrations. How can Claim Scrubber help improve claims management? Claim Scrubber optimizes claims processing by providing revenue cycle decision-makers and their teams with solutions that identify potential coding and billing errors upfront, ensure error-free claims submission to payers or clearinghouses, prevent undercharges and underpayment, increase first-time pass rates and prevent costly, time-consuming rework and rebilling that may result in a second rejection. Additionally, Claim Scrubber enables healthcare organizations to comply with and meet price transparency rules by staying updated on coding variances. Users can also revise flagged claims, ensuring appropriate and accurate corrections are made with access to Experian Health's extensive commercial payer policies and content database. Claim scrubbing occurs within 2.7–3.0 seconds, ensuring speedy transaction processing that leads to faster reimbursements. Healthcare organizations can also enjoy these benefits without the hassle of needing servers, regular maintenance and downtime with Experian Health's cloud-based application. See how State of Franklin Healthcare Associates used Claim Scrubber to expedite accounts receivable (A/R) by 13% and reduced full-time employee (FTE) requirements even as claims volume grew. Read the case study Healthcare organizations that automate claims management gain advantages that benefit all stakeholders and bottom lines. Claim Scrubber enhances operational efficiency, staff productivity, resource utilization, patient experience and satisfaction and hospital cash flow and financial growth. Contact us today to learn how Experian Health's Claim Scrubber software can help your healthcare organization submit clean, thorough claims and get paid faster and more accurately. Learn more Contact us

“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.

Slow communications, confusing billing and a scarcity of digital options are the last things patients want to deal with when seeking medical care. Yet, this is exactly what happens for too many – and it's a significant financial risk for providers. This article examines why the patient experience matters and suggests four areas for improvement. Specifically, it looks at the digital tools that put patients in the driving seat and boost patient satisfaction and profitability. What is the patient experience? Improving the patient experience starts with answering the following question: what does receiving care feel like to patients at each stage of their healthcare journey? The patient experience includes all the touchpoints between patients and their providers, such as scheduling appointments, attending consultations, collecting prescriptions, and settling bills. There are also intangible components like empathy, respect, trust, and transparency, which shape a patient's lasting impressions of the healthcare organization. The experience goes beyond clinical care and face-to-face moments: back-end processes matter, too. Administrative workflows like insurance verification and claims management may be hidden behind the scenes, but they can soon influence what care “feels like” to patients if they're not running smoothly. Why is the patient experience so important to healthcare organizations? When patients have a positive experience, they're more likely to attend appointments, adhere to treatment plans and make healthier lifestyle choices. Health outcomes improve and the provider can build their reputation as a top choice for quality care. Satisfied patients are less likely to switch providers and are more likely to recommend services to family and friends. Everyone wants their loved ones to get the best possible care. The strong through-line from the patient experience to profitability tops the list for revenue cycle managers. Well-designed patient flows lead to better resource utilization, while improvements in attraction and retention rates directly benefit the bottom line. Positive patient feedback improves staff morale, so performance remains high. Prioritizing the patient experience is not only beneficial for patients, but is an essential strategy for financial sustainability. How to improve the patient experience in healthcare So, what do patients want? Experian Health's State of Patient Access 2024 report shows they want convenience, simplicity and choice, with 60% of patients saying they want more digital options to manage their care. They don't want to be passengers in their healthcare journey: they want to be the drivers, but with the support of a trusted guide. That's where digital tools come in. Here are four ways to use digital tools to improve the patient experience in healthcare: 1. Give patients speedy access to care with online self-scheduling Almost 8 in 10 dissatisfied patients say seeing their doctor quickly is their biggest challenge when accessing care. Online self-scheduling puts patients in charge and accelerates the process by making it easier for patients to find, book and cancel appointments, using an intuitive digital platform. Automated integration with the organization's business rules and calendars means patients only see appropriate appointments. This software maximizes patient show rates with appointments accurately matched to patients' needs. Case study: See how IU Health transformed patient scheduling with automation. 2. Simplify the financial experience with transparent pricing and payment plans Paying for healthcare is notoriously complex. Providers can simplify the patient experience with digital tools that deliver accurate pre-care estimates and flexible payment plans. Experian Health's Patient Payments Estimates solution uses data and automation to help providers give patients an early heads-up about what their bills are likely to be, and directs them to the most suitable financial pathway. In addition, offering hassle-free, secure payment options makes it easier for patients to pay their bills promptly, reducing the risk of bad debt for providers. Case study: See how Blessing Health System used integrated revenue cycle solutions to improve the patient financial experience and increase point of service collections by over 80%. 3. Personalize the patient experience with tailored outreach One of the major advantages of using digital tools is the ability to offer a personalized experience. These tools segment patients for tailored and targeted outreach based on their needs and preferences. This helps providers communicate with patients via their preferred channels and encourages prompt action. For example, text message and interactive voice response campaigns enable target outreach at scale to help accelerate scheduling and referrals and close gaps in care. Case study: See how Dayton Children's Hospital used PatientDial to increase outbound call efficiency. 4. Streamline back-office workflows for a frictionless front-end experience Finally, providers should consider how administrative processes affect what's happening in the front office and waiting room. Neglecting back-end processes can lead to bottlenecks, errors and inefficiencies that compromise the overall quality of the patient experience. Automated, data-driven revenue cycle management solutions not only eliminate time-wasting manual processes and help providers reduce errors and rework, but they also elevate the patient experience by reducing data errors and delays. Implementing tools like Patient Access Curator can also help take the pain out of registration and scheduling for patients, by capturing all patient data at registration with an all-in-one, single-click solution. By making every patient-provider interaction as simple and supportive as possible, healthcare organizations can build a patient experience that inspires loyalty, trust and engagement. With a bit of help from the right data and digital tools, providers can deliver a better patient experience and, in turn, secure financial sustainability. Find out more about how Experian Health's digital patient engagement solutions can boost patient satisfaction and provider profitability.

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

The State of Patient Access 2024 is the fourth in a series of patient and provider surveys that began in 2020. This year's report compares how patients experience access to care and providers' perceptions of those experiences. This blog post highlights findings from the survey, which was conducted in February 2024 and is based on 200 healthcare revenue cycle decision-makers and more than 1,000 patients. The study finds that perceptions of access to care are improving. It's a positive sign that providers are moving in the right direction—but there are still have mountains to climb. What remains the same from prior surveys is that providers believe access to care is much better than what their patients are truly experiencing. The survey showed 55% of healthcare providers believe patient access has improved. It's a big jump from 2022, when just 27% of doctors felt access increased. What's striking, however, is that patients don't completely agree. Only 28% say patient access improved in 2023, an 11% increase from the prior year. Over half (51%) of patients and 26% of providers say patient access has remained fairly static. While the findings show access is improving, there is still a gap between patient experience and provider perception. How can providers improve care access and make their perceptions a reality for their patients? Download The State of Patient Access 2024 report to get the perspectives from patients and providers on their perceptions of access to healthcare. Myths vs. realities of patient access The good news from the survey is that most providers and patients agree access to care isn't worsening. Despite increasing patient volumes and chronic staff shortages, patient access is better than before the pandemic. The findings are a sharp reversal from last year's report, where almost one-half of providers and one-fifth of patients reported care access had grown more challenging. Patient access is: Better Patients: 28% Providers: 55% The same Patients: 51% Providers: 26% Worse Patients: 22% Providers: 20% Consistently, across these annual surveys, providers believe access to care delivery is better than what their patients experience. The survey highlights opportunities to bridge this gap by using digital technologies to align the patient experience and provider assumptions. Opportunity 1: Provide accurate upfront financial estimates 96% of patients want an accurate upfront estimate of treatment costs. 88% of providers agree an accurate upfront estimate contributes to successful patient payments. The survey showed upfront cost estimates are central to a better patient experience. A high percentage of patients (96%) said an accurate estimate of treatment costs is essential before service—so crucial that 43% said they would cancel their procedure without it. Yet 64% of patients did not receive a cost estimate before care, despite increasing state and federal regulations that require this transparency. Perhaps even more troubling, the accuracy for those estimates is questionable. Of the 31% of patients who received a pre-procedure cost estimate, 14% reported the final cost was much higher than anticipated. At the same time, 85% of providers say their estimates are accurate most or all the time. The gap in provider perception and patient reality come together at the point of understanding the need for accurate cost estimates. Understanding what is covered by insurance helps patients manage their healthcare costs. Providers are invested in getting estimates correct because they are a key part of getting paid on time, in full. Patient payment estimates software can automatically create a more accurate picture of costs, reducing the burden on healthcare staff and eliminating unwelcome patient surprises. Consolidating service pricing estimate data from multiple sources empowers patient accountability and decision-making. One health system used these digital tools to increase point-of-service patient collections by nearly 60%, producing estimates that were 80 to 90% accurate. Opportunity 2: Improve data collection at patient intake 85% of patients dislike repetitive paperwork during the intake process. Almost half (49%) of providers say patient information errors are a primary cause of denied claims. The survey showed patients and providers are frustrated with the data collections process during registration. More than eight of 10 providers say automation could improve this process. Yet, in practice, intake remains primarily manual. Patients complain they shouldn't have to complete the same paperwork at each visit. Providers know these manual tasks lead to errors that cause big headaches for claims departments later. However, only 31% consider improving the speed and accuracy of collecting patient information a priority. The top reasons for claim denials are paperwork inaccuracies and missing or incomplete claim information. Human errors cause challenges when it's time for providers to get paid. Up to 50% of claims denials stem from a paperwork processing error at patient intake. As a result, in 2022 alone, healthcare providers spent nearly $20 billion pursuing reimbursement denials. Everyone agrees that providers must do all they can to prevent errors. Providers understand claims denials are a significant roadblock to cash flow. Patients grow frustrated when account balances remain in limbo long after their procedure is complete. Digital technology can streamline patient access and transform the healthcare revenue cycle. Experian Health's Patient Access Curator solution can check eligibility, COB, MBI, demographics, insurance coverage, and financial status in less than 30 seconds, in one click, speeding up the laborious human intake process that creates anxiety—and errors—for patients and providers. Opportunity 3: Give patients online self-service options 89% of patients said the ability to schedule appointments anytime via online or mobile tools is important. 63% of providers have or plan to implement self-scheduling options. According to this year's survey, self-scheduling is hot; waiting on hold with a call center is not. Digital and paperless pre-registration is increasingly important to patients and there is evidence that providers are finally starting to listen. For example, 84% of the providers strongly agreed that digital and mobile access is important to patients. However, self-scheduling did not make the list of the top three provider priorities for improving patient access to care. But the data tells us patients hold out hope for a mobile-first online scheduling process that puts them in the driver's seat to control their access to care. Convenient online scheduling software gives patients control over booking, canceling, and rescheduling appointments. It's a digital front door that's easy to use across any device. Automated notifications can remind patients of annual health exams, replacing the need for staff calls and closing any gaps in preventative care. These tools can reduce time spent scheduling patients by 50% and significantly decrease appointment no-shows. More importantly, they give patients the digital experience they demand. Digital technology brings together patient experience and provider perceptions The State of Patient Access 2024 survey illustrates a narrowing gap between what providers perceive and patients experience. That's good news because a lack of access to healthcare is a contributing factor to a sicker population, which costs much more in the long run. According to Deloitte, barriers to accessing healthcare in this country will grow to a $1 trillion problem by 2040. Patients will continue to experience care access issues in the coming years, from staffing shortages and a lack of rural providers, higher co-pays and more. Can we bridge these future gaps? The answer is a resounding yes. While there's still work to do, the survey showed that 79% of providers plan to invest in patient access improvements soon. Download The State of Patient Access 2024 to get the full survey results, or contact us to see how Experian Health can help your organization improve patient access. 

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

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