Tag: claims management

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

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

Labor shortages and the uptick in claim denials are undoubtedly putting heavy financial strain on healthcare providers. Could automated claim denial prevention help ease the pressure? In a recent webinar, Jason Considine, Chief Commercial Officer at Experian Health, and Jordan Levitt, Co-founder at Wave HDC (recently acquired by Experian Health), discussed strategies to tackle denials head-on in the coming year. This article summarizes the key insights, including a new automated one-click denial prevention tool that shifts denials management to the front end of the revenue cycle. 5 revenue cycle challenges causing claim denials and strained margins To start, Considine opened the webinar with a discussion of the root causes of denials. These often originate during registration, and for many providers, “registration and data integrity continue to be a problem.” A fifth of denials are attributed to just five key issues: Coordination of benefits (COB) denials, which account for a major portion of denials as more patients have secondary and tertiary coverage; Contingency fees, which eat up margins in exchange for information that providers should be able to obtain themselves during registration; Labor costs, which can increase with labor-saving automations that push manual input downstream; Epic plan mapping, which becomes increasingly complex and error-prone as payer requirements evolve; Transactional pricing, where “pay-per-click” pricing models disincentivize providers from using registration tools to find patient information during registration. These interrelated issues should be solved with one up-front revenue cycle management (RCM) solution, rather than piecemeal fixes that are implemented later. According to Considine: “Vendors tend to offer ways to solve these problems after the patient leaves, but really we should have gotten the right information right up front. Pushing problem-solving downstream means you need more people to manage these solutions, you've got more vendors to manage, and you end up staffing denial management departments and throwing more people at the problem.” Shifting from denial management to denial prevention Part of the challenge is the sheer volume of patient information that must be collected from the start. Staff interact with multiple systems to collate, check and coordinate data on eligibility, COB, Medicare Beneficiary Identifiers, demographics and coverage. Many of these data points can be points of failure if the wrong information is captured and penetrates the rest of the system. This makes patient access the perfect place to solve the denials problem. Levitt says this is exactly what Wave HDC set out to do when they developed the technology that underpins Patient Access Curator. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within two to thirty seconds.” Patient Access Curator prevents denials by capturing all patient data at registration through a single click solution that returns multiple results in less than a minute. It's fast because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer. This means data can be transferred easily between interfaces. Levitt explained how the tool builds a “perimeter defense against bad data,” by ensuring data accuracy from the start. Bad data is less likely to propagate through the system, which reduces the risk of denials. As a result, clients using the tool have been able to reduce contingency volume by over 60%. Introducing the next generation of smart RCM technology Many organizations are investing in staffing to address claim denials, but this approach is not effective in the long run. Levitt described how preventing denials calls for technology that's built for today's challenges. “Most tools out there are built to manage the problems of the last twenty years. But twenty years ago, we didn't really have COB issues. Patients were either insured or uninsured. Now, some are over-insured and some are under-insured. You see more patients come in with one insurance card in their hand, but with two, three, or four other coverages. It's much more complex. Patient Access Curator makes it simple by bundling all the transactions into one.” The technology uses artificial intelligence, in-memory analytics, and robotic process automation to verify eligibility and COB, find and fix patient identifiers, check contact information, and generate information about the patient's propensity to pay. And the result? Providers can simplify denials management even as the insurance and operational landscape becomes more complex. Watch the webinar to hear the full discussion and find out more about how Patient Access Curator helps healthcare organizations capture accurate patient information at registration with a single click.

In a strategic move that will take claims management to the next level, Experian Health recently acquired Wave HDC, a healthcare technology company specializing in AI-guided data capture and curation. The acquisition brings together the two companies' capabilities to offer healthcare organizations faster and more accurate healthcare coverage identification. With this acquisition comes Patient Access Curator, a new solution that uses artificial intelligence (AI) to revolutionize the claims management process. Tom Cox, President at Experian Health, says, “With our vast clearinghouse data resources and Wave HDC's technology and expertise in insurance data capture processes, Experian Health now offers the best eligibility and insurance identification products in the market.” This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds. Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. Watch now Prevent denials on the front end Managing claims effectively – or more specifically, preventing denials – is one of the biggest challenges for providers. In a 2022 survey by Experian Health, 72% of respondents said reducing denials was their top priority, citing reasons including payer policy changes, reimbursement delays, and a rise in the number of errors and denials. Most issues that lead to denials crop up early in the revenue cycle, when information is missed or captured incorrectly during patient registration. For this reason, it makes sense to focus denial prevention strategies on the front end. With so much data to capture, manual strategies are bound to stumble. Unfortunately, many digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility and check for any billable coverage that might have been missed. Experian Health's industry-leading claims management products are designed to simplify these processes. The integration of Wave HDC's AI-powered data capture technology strengthens that offer with capabilities previously not available. As Cox says: “Our mission is to simplify healthcare, and this move allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” For Jordan Levitt, co-founder of Wave HDC, the merger is a chance to bring their unique technology to more healthcare organizations. “We believe this integration will have a powerful impact for the healthcare industry, improving financial solvency and efficiencies for providers through more accurate medical billing, resulting in potentially more reimbursement, faster.” Introducing Patient Access Curator: Claims management in a single click Wave HDC's technology captures and processes patient insurance data at registration using an “if-then” logic that returns multiple data points from a single inquiry, in 30 seconds. Through Patient Access Curator, registration staff can leverage this technology to collect and verify much of the information they need to compile an accurate claim, with just a single click. In a matter of seconds, they'll have a comprehensive readout of the following: Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps; Coordination of Benefits (COB): Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing; Medicare Beneficiary Identifiers (MBI): PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support; Insurance discovery: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches; Demographics: Lastly, but by no means least, the platform can quickly check and correct patient contact information. Providers can hear more about shifting denials management to the front end of the revenue cycle with Patient Access Curator on a recent on-demand webinar hosted by Jordan Levitt and Jason Considine, Chief Commercial Officer at Experian Health. On the webinar, Levitt explains that Patient Access Curator achieves such speedy results “because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer.” This means data can be transferred easily between interfaces. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within thirty seconds.” Maximize dollars, minimize workload Patient Access Curator moves away from manual methods and verifies eligibility and coverage automatically, quickly and accurately. But the platform promises more than efficiency; with this technology, Wave HDC has prevented denials of over $1 billion since 2020. At a time when revenue cycles are under increasing pressure from changing payer rules, labor dynamics and operational constraints, the new integration offers a long-awaited boost to both reimbursement rates and productivity. Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us

The relationship between hospitals and payers has often carried an undercurrent of tension. Stacks of paperwork, complex claims rules and manual adjustments are a recipe for disrupted cash flow and time-consuming rework. With profit margins hanging in the balance, providers need the reimbursement process to move forward without a hitch. To the relief of revenue cycle managers, recent developments in digital technology are paving the way for more effective claims management. Case in point: Experian Health's recent acquisition of Wave HDC, which brings together a suite of advanced patient registration solutions for faster and more accurate claims management at the front end of the process. Shifting sands in the hospital-payer relationship could increase denials For healthcare organizations, getting paid in full- and on-time hinges on seamless communications with payers. Any missteps can lead to revenue losses, with denied claims and delayed payments being the outcomes providers most want to avoid. Payers will automatically deny claims that have errors or missing information, while disputes and slow processing times can seriously hamper a hospital's cash flow. The sources of potential conflict have been pretty steady over time, stemming from complex billing processes, frequent changes to payers' requirements, and a lack of standardization between payers.  Tension created by the cost of services and the need to control healthcare costs is a constant in the revenue cycle. Recently, a major shift in dynamics has occurred with the widespread adoption of artificial intelligence by payers. This enables them to process – and deny – claims with unprecedented speed and scale, leaving providers struggling to catch up. On a recent webinar, Makenzie Smith, Experian Health Product Manager for AI AdvantageTM, explained how this change was reshaping the relationship between payers and providers: “So many payer decisions are now being driven by artificial intelligence. Insurers are reviewing and denying at scale using intelligent logic, leaving providers fighting harder for every dollar… Many revenue cycle managers will stick in their comfort zone because operating margins are tight and changing course seems risky. But given this change in payer behavior, the cost of staying the course could put organizations at risk.” How AI-powered revenue cycle management solutions help close the gap between payers and providers Providers are increasingly leveraging digital technology to level the playing field with payers. Integrated software and automation give revenue cycle management teams the right data in the right format and at the right time to respond to queries promptly and accurately. These solutions enable teams to work more efficiently, so they can process more claims in less time. Experian Health's flagship AI-based claims management solution, AI AdvantageTM, is a prime example. This tool predicts and prevents denials by identifying patterns in payer behavior and flagging claims with a high probability of denial so specialists can intervene before the claim is sent to the payer. This works alongside ClaimSource®, which automates clean claim submissions at scale. Using a single application, all claims are prepared and submitted with all necessary documentation, reducing the risk of denial due to missing or inaccurate information. Integrating Wave HDC's data capture technology for comprehensive claims management In November 2023, Experian Health acquired Wave HDC, which specializes in using AI-guided solutions to capture and process patient insurance data at registration with unrivalled speed and accuracy. This gives Experian Health clients access to a single denial management solution, known as Patient Access Curator. This new technology is a single click solution that spans eligibility verification, coordination of benefits, coverage and financial status checks with near-100% accuracy in less than 30 seconds. Crucial registration data can be captured in real time as soon as the patient checks in for an appointment, with no need to chase and update data post-registration. A single inquiry can search for all the essential insurance and patient demographics instantly, enabling better use of staff resources and smoother communications with payers. Tom Cox, President of Experian Health, says the move “allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” Accurate patient data from the outset is key to preventing downstream denials, many of which originate in patient access. By reducing errors and enabling faster processing times, this comprehensive approach to denial management will help strengthen the relationship between providers and payers, ensuring timely payments and clean claims. Contact Experian Health today to find out how AI and automation can help build a successful relationship between providers and payers – and drive down denials.

Experian Health ranked #1 in Best In KLAS for our ClaimSource® claims management system and Contract Manager and Analysis product – for the second consecutive year. The rankings were revealed in the annual 2024 Best in KLAS Awards – Software and Services, published on February 7, 2024. The Awards recognize the top software and services vendors that are helping American healthcare professionals deliver the best possible patient care, based on feedback from thousands of providers. Experian Health topped the list in two categories: ClaimSource ranked #1 in Claims Management and Clearinghouse. This automated and scalable solution reduces denials and increases revenue through a single application. The addition of an artificial intelligence component this year (AI AdvantageTM) is helping providers cut denial rates to just 4%, compared to an industry average of more than 10%. Contract Manager and Analysis ranked #1 in Revenue Cycle: Contract Management. This product levels the playing field with payers by monitoring compliance with contract terms and recovering underpayments. It also arms providers with financial models of proposed contracts, so they can negotiate more favorable terms. Case study: See how Hattiesburg Clinic in Mississippi uses ClaimSource to automate claims management and reduce denials. The awards come as the industry grapples with ongoing staffing challenges and rising claim denials. In Experian Health's 2023 report on the healthcare staffing crisis, 100% of respondents saw staffing shortages affect revenue cycle management and patient engagement. As the pressure continues, revenue cycle technology offers a way to increase efficiency and improve financial performance.  “Healthcare professionals face immense pressures, ranging from financial strains to staffing shortages and the very real issue of clinician burnout,” says Adam Gale, CEO and Founder of KLAS Research. “We want to provide actionable insights that will ultimately alleviate burdens and enhance clinician success.” For Tom Cox, President of Experian Health, the awards reflect a continuing commitment to help providers optimize operations and patient engagement using data-driven insights and technology. “This recognition from KLAS recognizes our dedication to deliver innovative solutions that not only improve the financial health of providers but also the patient experience. Receiving this award two years in a row is an honor as we remain steadfast in our commitment to simplifying healthcare through technology.” Find out more about how ClaimSource and Contract Manager and Contract Analysis helps healthcare organizations increase efficiency and boost financial performance.

Healthcare is a challenging profession. Providers understand that their mission of care delivery is fueled by the revenues they capture; after all, it is the business of healthcare. However, capturing revenues through the claims management process is burdensome and complex. Denials are all too common, hampered by inefficient workflows and manual tasks. As a result, it slows down reimbursement and impacts revenue. Moving toward reliable claim acceptance requires the strategic use of automation and technology to reduce denials. These initiatives accelerate the cycle of payments, improve cash flow, and ease strains on existing staff. This article takes a deep dive into the challenges of healthcare claims processing and strategies to help providers transform the claims management process. Challenges of healthcare claims processing The healthcare claims management process desperately needs modernization and optimization. Last year, an Experian Health survey showed that three out of four providers say reducing claims denials is their top priority. What's making it so difficult for providers to get paid? The healthcare reimbursement journey Let's start with the typical claims management process. Step 1: Prior authorization The first issue is that most generally accepted standard practices in healthcare claims processing create a long journey for provider reimbursements. This journey starts even before patient care, at eligibility and preauthorization. The American Medical Association (AMA) states, “Prior authorization is a huge administrative burden for physician practices that often delays patient care.” While prior authorization may help insurance companies reduce the cost of “unnecessary” treatments, the data shows it's having the opposite effect on the providers themselves. An AMA physician survey shows that 86% of prior authorizations lead to higher overall utilization of services. The practice doesn't appear to help patients, either; the AMA says 94% of doctors report care delays related to prior authorization, and 82% say patients abandon their treatment plans due to prior authorization struggles. Step 2: Data capture The second part of healthcare claims processing begins after the patient encounter. It involves many manual tasks, often leading to errors and claim denials. Intake and billing specialists must gather data from multiple sources for coding claims, including electronic health records (EHRs), physician notes, diagnosis codes, paper files, and the patients themselves. These workflows require significant manual data entry and review, which is impacted further when codes or insurance reimbursement requirements are out-of-date in provider systems. A recent survey shows that 42% of providers report code inaccuracies, and 33% say missing or inaccurate claims data as the top reasons for rejected claims. Step 3: Processing claims denials Post-submittal, there's more work when claims bounce back. It's part of the claims management process with the most inefficiencies and friction, costing the average provider millions annually. Healthcare providers experience Experian Health survey—but that number is rising. Responses from Experian Health's State of Claims 2022 report revealed that 30% of respondents experience denials increases of 10 to 15% annually. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand the current state of claims management. Watch the video to see the results: These challenges illustrate the need for modern and optimized healthcare claims processing. With this lens in place, healthcare providers can apply more effective claims management strategies to increase claims accuracy and reimbursement and reduce denials. Innovating your claims management strategy Healthcare professionals and organizations can proactively address challenges in the claims acceptance process by implementing effective strategies to optimize revenue cycle management. This effort should include the following: A cohesive and comprehensive claims management processNew approaches to outdated claims management workflows will address gaps, inefficiencies, and errors. Upgrading to a turnkey insurance claims manager can reduce denials and speed up claims processing. Address data quality and consolidationThe sheer volume of data required for healthcare claims processing increases the risk of errors. If the data isn't accurate at the front end, it's a fast track to denial. But claims go through multiple touch points in disparate systems without a single source of control and oversight. Organizations can employ standards for data intake to reduce inaccurate or incomplete patient information and duplicates and leverage technology to aggregate data from the multiple sources needed for claims processing. Implement best practices for denial workflowsClaim denial management on the backend of healthcare claims processing is even more challenging than capturing patient data at the front end of the encounter. Managing claims denials is time-consuming, and delays reimbursements, but denial workflow technology can streamline all follow-up activities. With this support, billers have less administrative work and can stretch farther, alleviating the burden of staffing shortages. Deploy tools for analysis and prioritizationA claims management platform can automatically analyze the components of each claim. With this information, the technology can prioritize denials workloads so high-impact accounts get the most attention. Upgrade claims technology automation with artificial intelligence (AI)Providers can transform claims management with a technology update. According to the State of Claims report, almost half of organizations replaced legacy healthcare claims processing technology in the past year. A vital component of this upgrade includes expanded automation capabilities that stretch the workforce further. Solutions like AI Advantage™ can help speed up the claims management process by predicting and preventing denials. Add prior authorization softwareAnalysis suggests that healthcare could automate up to 33% of manual tasks. Research on the benefits of automation showcases its potential for decreasing errors and other reimbursement obstacles. With prior authorization software, task assignment is seamless, and AI adds even more functionality with predictive capabilities. Accelerate claim follow upMonitoring claim status is another aspect of the payment ecosystem that heavily impacts provider cash flow. Technology automates much of this workflow. Organizations can adopt functionality that eliminates manual follow-up tasks to accelerate an unwieldy process. These solutions enable providers to respond quickly to issues, enhancing productivity beyond basic ANSI 277 claims status responses. Technology is the unifying thread behind a cohesive claims management strategy for any healthcare provider struggling with a high rate of denials. While 61% of providers lack automation in the claims/denials process, increasing evidence shows these tools drive revenue cycle efficiencies that transform claims denials management. Forward-thinking organizations like Summit Medical Group Oregon—Bend Memorial Clinic (BMC) leverage Enhanced Claim Status and Claim Scrubber to achieve a 92% primary clean claims rate. Schneck Medical Center uses AI Advantage to denials by an average of 4.6% each month. Implementing effective claims management strategies Strategies rooted in reliable, practical technology transform the claims management process. Healthcare organizations benefit from AI-driven automation solutions as part of an overarching claims management strategy that streamlines workflows, reduces denials, and boosts cash flow. Experian Health offers a portfolio of provider claims management tools to help organizations realize effective claims management process improvements to get paid faster. Learn more about the No. 1 Best in KLAS 2023 Claims Management and Clearinghouse tools or contact us to see how Experian Health can help improve your claims management processes.

Today, U.S. healthcare providers struggle with three significant challenges affecting care delivery—each resulting from chronic healthcare workforce shortages. Ultimately, these challenges threaten the fiscal health of the country's most critical care safety nets. Over 80% of the healthcare C-suite say the chronic staffing shortage creates significant risk for their organizations. The effects of healthcare staffing shortages are severe - Experian Health's recent survey of revenue cycle leaders found these executives unanimously agreed that staffing shortages impact cash flow, patient engagement, and the work environment of their current staff. Experian Health’s new survey, Short Staffed for the Long-Term, polled 200 revenue cycle employees to determine the effects of healthcare staffing shortages on patients, the workforce, and their facilities. What did these teams say about the healthcare workforce shortage and the state of care delivery? Find out by downloading the full report. Healthcare providers experience a vicious cycle, and the effects of healthcare staffing shortages can be seen in many different areas. For example, it makes it harder for existing team members to register patients on the front end of the encounter. On the back end, revenue cycle staff face higher workloads and stress leading to preventable reimbursement claims errors and missed collections opportunities. Ultimately, that stress leads to staff turnover, exacerbating the healthcare workforce shortage. This article dives into three effects of healthcare staffing shortages and how providers can combat them. Result 1: Short-staffed providers struggle with reimbursement and cash flow. 70% of respondents who say staff shortages affect payer reimbursement also report escalating denial rates. 83% report it's harder to follow up on late payments or help patients struggling to pay their bills. Costs are up, and cash flow is down. Claims denials are increasing by 15% annually. Reimbursement rates continue to decline even as denials rise and patient debt increases. These are the revenue cycle challenges healthcare providers face on top of the chronic healthcare staffing shortage. Healthcare organizations must look for new ways to improve reimbursements while engaging patients and staff to benefit everyone involved. Experian Health's Short Staffed for the Long-Term report noted two of the most significant revenue channels for healthcare providers, claims reimbursement and collections, are experiencing significant challenges. Reimbursement denials tie up cash flow in an endless cat-and-mouse game of revenue collection. HealthLeaders termed 2023 as, “the year of reducing denials for revenue cycle.” Their statistics further reinforce Experian Health data correlating increasing denial rates with the healthcare staffing shortage. Simultaneously, healthcare providers find it harder to collect from patients. High self-pay costs lead to lower patient collection rates. One study showed patient collections declining from 76% in 2020 to 55% in 2021. Providers desperately need a more patient-centered collections process that helps these customers understand their cost obligations and payment options. Integrating automated collections solutions can also help providers do more with less. Healthcare stakeholders must collaborate to devise innovative solutions that prioritize workforce augmentation and streamline financial workflows. Technology can solve these problems by automating manual revenue cycle processes that lead to delayed reimbursements. New solutions that use artificial intelligence (AI) software can help in other areas (like claims denials) to save staff time and reduce workloads. Result 2: A lack of staff directly impacts successful patient engagement. Surveyed staff say 55% of patients experience engagement issues at scheduling and intake. 40% say patient estimates suffer, leading to potential miscommunications in credit and collections. Experian Health's The State of Patient Access, 2023: The Digital Front Door reported patients and providers believe healthcare access is worsening. 87% of providers in the survey blamed the effects of healthcare staffing shortages. Earlier data from ECRI shows patients wait longer for care, and nearly 50% of providers say access is worse. Over 100 academic studies in the past two decades confirm the correlation between poor patient health outcomes and industry staff shortages. Existing staff members may take on heavier workloads to cover gaps in patient care. The resulting fatigue can impact the quality of care delivery. When healthcare organizations are short-staffed, each team member may spend less time with patients, resulting in rushed assessments and potentially missed diagnoses. Staff shortages can impact every phase of the patient journey, beginning with patient scheduling and potentially delayed essential medical services. On the backend, patients suffer when the pressure staff members feel to work faster causes preventable errors leading to healthcare claim denials. Collections suffer, as frustrations mount, and healthcare staff waste time on patients who are simply unable to pay. The adverse effects of staffing shortages in healthcare weaken with technology to improve the patient experience at every stage of their encounter. Better technology lessens the burden of care for staff by automating mundane administrative tasks so every provider can focus on serving patients—not filling out forms. Improving patient engagement starts at the beginning of the healthcare encounter. For example, patient scheduling software can create a seamless online experience that halves appointment booking time. More than 70% of patients say they prefer the control these self-scheduling portals offer, putting access to care back in their hands. Patient payment estimation software creates much-needed healthcare price transparency, improving satisfaction by eliminating financial surprises after treatment. These solutions, combined with automated revenue cycle management software, can streamline healthcare processes and improve patient experiences. Result 3: Overwork is the norm as staff work environments decline and turnover increases. 37% of survey respondents report issues with staff burnout. 29% list the departure of experienced staff as one of their top challenges. Whether in frontend care delivery or backend revenue cycle, overworked and stressed healthcare professionals are more susceptible to making mistakes, diminishing the overall quality of the patient experience. The attention to detail, a critical component in a complex, high-stakes business, may be compromised due to the strain on the existing staff. When a healthcare organization is short-staffed, it increases the stress on the existing employees. In turn, this contributes to higher turnover rates. Job dissatisfaction and increased stress levels create a challenging work environment, perpetuating the cycle of staffing shortages. Recruiting and training new staff to fill these gaps further exacerbate the strain on existing teams. One area that is critically impacted by staffing shortages is seen in claims management, as claim denials continue to increase, which cost American healthcare providers an estimated 2.5% of their gross revenues annually. Billions of reimbursement dollars logjam in the endless cycle of claims submissions, rejections, and manual mitigations. In 2022, the cost of denials management increased by 67%. Revenue cycle staff, stretched to their limits by staffing shortages, will likely continue to make preventable mistakes during patient intake and claims submission. However, automating claims management with a solution like ClaimSource® can help lower denial rates and ease this burden.  This solution delivers increased operational efficiencies and effectiveness by prioritizing claims, payments and denials so that users can work the highest impact accounts first. Other solutions, like Claim Scrubber, can improve claim accuracy before submission, by submitting clean and accurate claims every time. These technologies enable healthcare providers to reduce claims denials while relieving some of the terrible pressure felt by their financial teams to work harder and faster. By automating clean claims submissions, healthcare organizations free up their teams to focus on taking better care of patients—and themselves. Healthcare staffing shortages + manual revenue cycle = Unsustainability What happens to a process that heavily relies on human labor—when there aren’t enough people to go around? In the case of the healthcare revenue cycle, it means staffing shortages heavily impact a hospital's ability to collect revenue. Medical Economics reports that 78% of providers still conduct patient collections with traditional paper statements or other manual processes. In an era of talent shortages, these manual processes bog down the entire organization with no relief in sight. Overwork leads to burnout, a significant problem in the industry that also contributes to staff turnover. But this is exactly how digital technology can solve the healthcare staffing shortage. While AI and automation can’t help providers find the staff they need, it can eliminate manual tasks and reduce errors that lead to more work, staff burnout, and patient care disruption. McKinsey says automation can eliminate approximately half of the activities employees now perform. It could considerably improve the work environments for revenue cycle staff, allowing them to focus on high-value tasks, and engage patients in more caring and personalized experiences. Experian Health offers providers proven technologies to increase revenue, improve patient care, and lessen the strain on existing staff, to combat the effects of healthcare staffing shortages. Contact Experian Health today to get started.

Like many other sectors, healthcare providers are increasingly turning to automation and artificial intelligence (AI) to get more accurate data and better insights. However, the pace of change 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 in innovative ways. This is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for AI to help maximize reimbursements. This article looks how AI and automation can help providers address the problem of growing denials, and how Experian Health's new solution, AI Advantage™, is helping one particular provider use AI to reduce claim denials. Using AI and automation to address the claims challenge 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. Changing payer policies and a changing payer mix layer on complexity. Labor shortages mean fewer hands on deck to deal with the workload, while rising costs and tighter margins mean the stakes are higher than ever. Manual claims management tools simply cannot keep up, resulting in lost time and revenue. 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 patterns in data, and synthesizing huge swathes of data to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation can be used to complete rules-based, repetitive tasks with greater speed and reliability than a person might be able to achieve. Discovering new use cases for AI in claims management Providers are finding new applications for AI as utilization becomes more widespread. Some examples of different use cases include: Automating claims processing to alleviate staffing shortages: AI tools can use natural language processing (NLP) to extract data from medical records and verify accuracy before adding the information to claims forms. This saves staff significant amounts of time and effort. Augmenting staff capacity and creating an efficient working environment can also help with recruitment and retention. Reviewing documentation to reduce coding errors: AI can perform the role of a “virtual coder,” using robotic process automation and machine learning to sift through medical data and suggest the most appropriate codes before claims are submitted. Using predictive analytics to increase operational efficiency: One of the most effective ways to improve claims management is to review and learn from past performance. 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. Improving patient and payer communications with AI-driven bots: The claims process requires large amounts of data to be exchanged between providers, payers and patients. AI-driven bots can be used to take care of much of this, for example by automatically responding to payers' requests for information during medical necessity reviews, or handling basic inquiries from patients. Case study: How Community Medical Centers uses AI Advantage to predict and prevent claims 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 that are 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 turnovers. AI Advantage eases the pressure by automatically detecting changes in the way 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 any 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.” Hear Eric Eckhart of Community Medical Centers and Skylar Earley of Schneck Medical Center discuss how AI Advantage improved their claims management workflows. AI AdvantageTM: two steps to reducing claim denials AI Advantage works in two stages. Part 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, this helps providers prevent denials before they occur. Part 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 make the biggest impact to their bottom line. At CMC, denials teams had previously focused on high value claims first, but found that smaller payers sometimes made erroneous denials that could add up over time. AI Advantage helped root these out so Eckhart's team could resolve the issue with payers. Integrated workflows reveal new applications for AI and automation AI Advantage works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. In this way, AI Advantage fits into the same workflow as tools that providers may already be using, such as Claim Scrubber, Enhanced Claim Status and Denials Workflow Manager. These integrations amplify the benefits of each individual tool, giving healthcare providers better insights into their claims and denials data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Discover how AI Advantage, Experian Health's new claims management solution, can help providers use AI to reduce claim denials.