Tag: claims management

As economists offer up their best guesses for the US economy over the coming year, healthcare leaders know one thing for sure: no matter what happens, they need solid revenue cycle management (RCM) processes to remain financially sound and deliver high-quality care. Revenue cycle management connects the financial and clinical aspects of care by ensuring that providers are properly reimbursed for their services, through accurate and efficient billing and claims management processes. Keeping the financial scales tipped in the right direction is a growing challenge: data from the American Hospital Association shows that payer delays and denials are driving up operational costs while slowing revenue. Many providers are turning to artificial intelligence (AI), automation and data analytics to eliminate inefficiencies and maximize reimbursement. Factors that affect healthcare revenue cycle management While revenue cycle math is pretty simple – money in versus money out – the reality is more complex. A tight grip on delivery costs is just one part of the equation. Most RCM efforts center around determining who owes what and collating the necessary documentation to secure prompt payment from each party. A few factors to consider include: Are there reliable processes for capturing accurate patient information? How quickly can coverage and pre-authorizations be verified? Are claims and denials managed efficiently? How easy is it for patients to understand and pay their bills? Can RCM leaders monitor and analyze staff and agency performance? Changing payer policies, patients' financial status and data management demands add to the challenge. The goal of revenue cycle management To achieve the primary aim of getting reimbursed in full and on time, organizations must reduce billing errors, submit clean claims and refine operational efficiency so staff can stay laser-focused on high-value tasks. But it's important to look beyond the spreadsheets: selecting the right tools to deliver a transparent and compassionate patient experience will boost the bottom line, too. History and evolution of RCM RCM has shifted from largely paper-based processes to sophisticated software-based systems in just a few decades. Few could have imagined how those early healthcare information systems of the 1970s would evolve as electronic health records, standardized coding frameworks and digital data processing came to the fore. Changes in regulation and reimbursement models furthered the need for advanced analytics. And now, the rise of healthcare consumerism drives demand for the industry to open its digital front door. Organizations that commit to digital transformation will be in a stronger position to navigate today's RCM challenges and meet the needs of digitally native consumers. Relationship between patient experience and RCM Experian Health's recently published State of Patient Access Survey 2024 reveals the extent to which the patient experience affects revenue. Integrating patient-centered principles into RCM processes improves patient satisfaction, makes it easier for patients to understand and pay their bills, and leads to better financial performance overall. Steps in the healthcare revenue cycle A typical revenue cycle management workflow in healthcare follows the patient’s journey. Each touchpoint in the patient's journey is an opportunity to check that patients, payers and back-off teams have the information they need to expedite payment: Scheduling – When the patient books an appointment, administrative staff verify the patient's insurance eligibility. This is a chance to make sure pricing is transparent and give the patient an estimate for the cost of care. Registration – Next, the provider captures the patients' medical history, insurance coverage and other demographics. Correct patient information on the front end reduces the errors that cause rework in the back office. Prior authorization – Front-end staff check whether the patient's insurance provider requires prior authorization for the procedure or service they need. Skipping this step can lead to costly denials and rework. Treatment and follow-up – After treatment, the back office collates billable charges and assigns a medical billing code to the claim. Accuracy is paramount, as reworking claim rejections can drain resources. Claim submission – Then, the claim must be submitted to the payer. Accurate and timely submissions prevent rejections and reimbursement delays. If a claim is denied, it must be resubmitted as quickly as possible to avoid lost revenue. Collections – Once the payer approves the claim, the patient's out-of-pocket costs are calculated and billed. Providing a range of convenient payment methods will increase the likelihood of prompt payment. Regulatory and compliance considerations At each stage in the process, staff must stay mindful of the regulatory and compliance frameworks governing revenue cycle management. These are primarily patient-centered. For example, the Health Insurance Portability and Accountability Act (HIPAA) safeguards patient privacy and sensitive health information, while the No Surprises Act seeks to make pricing more transparent. Failure to adhere brings severe reputational and financial risks, as made painfully clear by recent headlines about the cost of cyberattacks within the industry. Common challenges in healthcare RCM For most providers, avoiding the cycle of claim denials and rework is the biggest challenge. A survey of 1300 hospitals found that denials by commercial payers had increased by 20.2%, while Medicare Advantage denials had increased by 55.7% between January 2022 and July 2023. Reliance on inefficient manual processes to track and monitor claims does little to help. A 2023 CAQH report shows that switching from manual to electronic claim status inquiries could reduce the time spent on each transaction by 17 minutes, saving the medical industry more than $3.2 billion overall. Providers are also collecting increasing sums from self-pay patients. Financial pressures and uncertainty around coverage mean many patients cannot fully cover their medical expenses. Improving their financial journey with accurate upfront estimates, clear and compassionate communications, and convenient payment methods will accelerate payments. Unfortunately, there's still some way to go: the State of Patient Access Survey 2024 found that 64% of patients had not received a cost estimate before care, and of those that did, 14% reported final costs that were much higher than expected. Financial impact analysis To track the financial effects of these challenges, healthcare organizations should identify key performance indicators (KPIs) aligned to their specific priorities. Conducting real-time monitoring and analysis of patient access, collections, claims and contract management metrics can flag up opportunities to prevent revenue leakage and maximize income. Read more about how to identify the right KPIs for your revenue cycle dashboard. 4 ways to improve revenue cycle management in healthcare When it comes to implementing specific revenue cycle management solutions, the following four tactics are likely to yield the greatest return on investment: Automate AccessA healthy revenue cycle begins with quick, accurate and efficient patient access systems. Automated, data-driven workflows reduce the errors that lead to denials and rework. Online scheduling allows patients to easily book appointments, while solutions like Patient Access Curator use AI to capture all patient data at registration with a single click. Increase collectionsMaximizing patient collections while fostering a positive patient experience can be a delicate balance. Patient access staff must be the patient's advocate, while ensuring the organization collects what’s owed. Giving patients upfront estimates of their financial responsibility and offering appropriate financial plans makes it as easy as possible for them to pay. Collections Optimization Manager allows providers to focus their efforts on the right accounts, through highly predictive patient segmentation. Streamline claimsAutomating claims management is another way to use technology to accelerate reimbursement. Claims management software verifies that each claim is coded properly before being submitted. Encounters can be processed in real-time with automatic alerts to flag any issues before the claim is submitted. Experian Health's flagship AI Advantage™ solution helps predict and prevent denials by checking claims before they are submitted and calculating the probability of denial. It evaluates and segments denials that occur based on the likelihood of reimbursement following resubmission, and prioritizes the work queue so staff make the best use of time. Increase reimbursementHealthcare organizations that don't stay current on payer policy and procedure changes risk payment delays and lost revenue. Providers and payers must be on the same page to quickly resolve mismatches between expected and actual reimbursement amounts. Automated payer policy and procedure change notifications help providers strengthen relationships with payers and avoid payment delays. How healthy is your revenue cycle? Our revenue cycle management checklist helps healthcare organizations catch inefficiencies and find opportunities to boost cash flow. Case studies See how automated revenue cycle solutions helped Stanford Health optimize their patient collections strategy. See how Schneck Medical Center prevents claim denials with AI AdvantageTM Hear how UC San Diego Health used automation to improve patient billing and drive collections. Getting the most out of revenue cycle management software These case studies demonstrate that a successful revenue management strategy has three essential ingredients: data, software and training. Experian Health's “Best in KLAS” revenue cycle management solutions are built on proven technology and proprietary databases, to help staff find new opportunities to bring in revenue. Experienced consultants are on hand to guide staff and ensure workflows are set up for the best results. The future of RCM Whatever the economic outlook, technology’s defining role in the future of revenue cycle management is undisputed. Payers are already leveraging AI to their advantage, and patients have come to expect convenient digital transactions—any providers that fail to embrace AI and automation-based RCM solutions will fall behind the competition. Learn more about how Experian Health's revenue cycle management solutions generate more revenue for healthcare organizations.

Millions of healthcare claims are denied annually, costing providers billions in lost revenue and expensive appeals. A 2024 survey shows that around 15% of all claims submitted to private payers, Medicare Advantage and Medicaid managed care plans are initially denied. Since most involve charges of $14,000 and above, the stakes are worryingly high. Frustratingly, more than half of these denials are eventually overturned, but not before providers have spent an average of $43.84 reworking each claim. With hospitals and health systems spending almost $20 billion on denial management in 2022 alone, this administrative tug-of-war with payers brings a substantial toll. While some denied claims are valid, there's no doubt that many are avoidable, as evidenced by the number that are successful on the second try. This is where effective claim denial management strategies and solutions come into play. Understanding the root cause of denials in healthcare and implementing the right systems ensures that claims are right the first time. This article looks at the importance of denial management, strategies for improvement, and why more providers are shifting from defense to offense by putting automation and artificial intelligence (AI) at the heart of their claims management processes. The importance of denial management in healthcare A traditional denial management definition in healthcare might focus on the steps needed to resolve denials after they occur. The reality is much broader. Providers need a proactive strategy that addresses why claims are denied in the first place to prevent them from occurring in the future. Claims may be denied because the insurer doesn't consider the treatment medically necessary, believes there's a cheaper alternative available or doesn't cover it because the patient's insurance doesn't cover it. Sometimes, the culprit is an erroneous billing code or typo. Providers avoid costly and time-consuming rework by ensuring that claims are accurate, compliant, and complete at the start. As denials become more common and costly, streamlining denial management is increasingly urgent. The provider-payer relationship One of the major challenges for providers is the shifting relationship with payers. According to a survey by the American Hospital Association (AHA), 78% of hospitals say interactions with commercial payers are getting worse, with 84% noting the rising costs of complying with insurer policies. Providers report spending more time on prior authorizations, yet the growing pile of denials includes pre-authorized services. The pattern of claims being denied and then granted on appeal drains financial resources, delays patient care and contributes to staff burnout. Moreover, payers have been much faster in adopting AI-based technology, allowing them to process and deny claims at an unprecedented rate. Providers that rely on traditional denial management methods are starting to fall behind. The denial management process: how it works Healthcare denial management involves four key steps: Track all claims from submission through final adjudication and identify denials as quickly as possible. Denials should be categorized by type, payer and service to identify trends and understand underlying issues that need addressing. Investigate the cause of each denied claim, such as coding errors, missing documentation or non-adherence to payer guidelines. This stage often involves collaboration among billing teams, coders and clinicians to pinpoint what went wrong. Rework the claim by gathering missing data or documents and correcting errors before resubmitting the claim to the payer for reconsideration. This will also include monitoring the outcome to see if the appeal is successful. Prevent future denials through improvement measures such as staff training, updates to billing software, and ongoing payer policy reviews. A preventive approach ensures claims are managed without a hitch and keeps revenue flowing. Strategies for effective healthcare denial management Prevent denials upstream with accurate patient access Because so many denials originate early in the revenue cycle, patient access should be the first target in any denial reduction strategy. Experian Health's Patient Access Curator solution uses AI-powered data capture technology to collect and verify patient information in seconds. A single click checks eligibility verification, coordination of benefits (COB), Medicare Beneficiary Identifiers (MBI), coverage discovery and financial information to determine the patient's propensity to pay quickly and accurately. Staff no longer need to run multiple queries and can have confidence that their claims are built on the correct data. Watch the webinar to learn how Patient Access Curator shifts denial management upstream and propagates clean data throughout the revenue cycle. Process denials more efficiently with workflow automation A second strategy is to automate the denials workflow to alleviate the administrative burden on staff and expedite the appeals process. Denial Workflow Manager automatically identifies denials, holds, suspends, zero pays and appeal status so staff can follow up quickly, without the need for manual reviews. They'll have the time and intel to rework the denials that are most likely to be overturned, resulting in maximum cash flow. When used alongside ClaimSource®, they can do all this using standardized protocols with claim and denial information on the same screen. Denial Workflow Manager provides American National Standards Institute (ANSI) reason and payer codes and descriptions so staff know precisely why a claim was denied. Reports and responses can be forwarded to Health Information and Practice Management Systems to facilitate better coordination. The tool also provides advanced analytics to identify trends and inform tactics for further improvement. This significantly reduces the overall time and cost associated with managing denials. The future of denial management in healthcare While automation has lifted healthcare denial management out of inefficient manual processes, AI takes predicting and preventing denials a step further. AI AdvantageTM enhances the denial management toolkit with two new offerings: Predictive Denials uses the provider's own claims data from within ClaimSource to identify claims that are most likely to be denied, so staff can step in to take corrective action before submitting the claim. Denial Triage analyses and segments denials that do occur so staff can focus on reworking claims with the highest potential for reimbursement. With these tools, providers can eliminate guesswork, reduce denials and minimize financial losses. But it's not just about finding more innovative ways of working: payers have already made huge strides in using AI to deny claims at speed and scale. The future of denial management in healthcare will hinge on technology, and providers will need to adapt to keep up with the fierce competition. Find out more about Experian Health's Denial Management Solutions and see why they're top-rated by clients in the 2024 Black BookTM RCM User Survey. Denial Management Solutions Contact us

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

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.