Tag: ClaimSource

Ask any healthcare revenue cycle manager how they feel about using artificial intelligence (AI), and the response is likely to be “hopeful, but wary.” The potential is clear — fewer denials, faster reimbursements and more efficient workflows. However, with adoption slowing, it seems many have lingering concerns about implementation. According to Experian Health's State of Claims survey, the number of providers using automation and AI in revenue cycle management has halved from 62% in 2022 to 31% in 2024. Despite these reservations, there are bright spots. From preventing claim denials to automating patient billing, AI and automation are already helping many healthcare organizations improve operations, boost financial performance and deliver a better patient experience. This article examines what providers need to know about bringing AI technology into their revenue cycle. Understanding the role of AI in revenue cycle management AI regularly hits the headlines for its clinical applications, like medical imaging analysis, drug discovery and surgical robotics. But behind the scenes, it's also quietly transforming revenue cycle management (RCM). Non-clinical processes like medical billing, claims management and patient payments are complex. Trying to manage these manually results in slow reimbursement and strained resources. AI offers efficient solutions to reshape how providers manage these pressing issues, giving them a head start in coping with increasing costs, workforce challenges and ever-increasing volumes of data. Benefits of AI in healthcare RCM  For most providers, AI's main draw is its ability to deliver significant financial savings. The most recent CAQH index report suggests that switching from manual to electronic administrative transactions could save the industry at least $18 billion. That's a compelling prospect for revenue cycle leaders looking to do more, and faster, with fewer resources. These financial savings aren't just the result of direct cost-cutting – they stem from the broader operational benefits AI brings to the table. These include: Streamlined billing processes: Automating repetitive tasks and minimizing human error reduces costly mistakes that lead to payment delays Fewer claim denials: Predictive analytics help staff identify claims that may be at risk of denial so that issues can be tackled upfront Real-time eligibility verification: AI tools can check a patient's insurance details in an instant, to catch outdated information and prevent billing mistakes and denials Better data insights: AI has the power to analyze vast datasets and find patterns and bottlenecks to help teams improve decision-making Productivity boost: With reduced admin overhead, staff can focus on higher-priority tasks and improve overall performance, with less stress and burnout. The benefits extend to patients, too. Behind every denied claim or billing error is a patient caught in administrative confusion. By automating processes, eliminating errors and increasing transparency, AI and automation help providers give patients financial clarity throughout their healthcare journey. How AI is revolutionizing healthcare RCM  Here are some examples of what this looks like in practice: Using AI to manage complex billing procedures Medical billing errors cost healthcare organizations millions of dollars each week, and the problem is only getting worse. Experian Health's State of Patient Access survey 2024 found that 49% of providers say patient information errors are a primary cause of claim denials, while in the State of Claims survey, 55% of providers said claim errors were increasing. Manual processes make managing the complexity of insurance plans, billing codes and patient payments near impossible. AI simplifies the task. For example, Patient Access Curator uses AI-powered data capture technology, robotic process automation, and machine learning to verify coverage and eligibility accurately with one click. This ensures accuracy throughout the billing cycle, reducing denials and accelerating collections. On-demand webinar: Watch our recorded session to hear how revenue cycle leaders from Exact Sciences and Trinity Health share their strategies and success stories with the Patient Access Curator. Using AI to prevent claim denials Claims can be denied for many reasons, but poor data consistently tops the list. Even so, around half of providers are still using manual systems to manage claims. AI helps providers buck the trend by improving data quality and using that data to improve claims management. Experian Health's AI AdvantageTM, available to those using the ClaimSource® automated claims management system, analyzes patterns and flags issues before claims are submitted, using providers' historical payment data together with Experian Health's payer datasets. It continuously learns and adapts, so results continue to improve over time. Read the case study: AI Advantage helped Schneck achieve a 4.6% average monthly decrease in denials in the first six months. Using AI to reduce patient payment delays The rise in high-deductible health plans is associated with a greater risk of missed patient payments. According to SOPA, 81% of patients said accurate estimates help them prepare for the cost of care, and 96% are looking for their provider to help them make sense of their insurance coverage. AI is vital for providers looking to help patients understand their financial responsibility early and avoid payment delays. With solutions like Patient Access Curator, staff no longer need to sift through piles of patient data and payer websites to verify eligibility and get a clear picture of a patient's insurance coverage. Instead, they can quickly gather the information they need to give the patient a prompt and accurate breakdown of how the cost of care will be split. "Within the first six months of implementing the Patient Access Curator, we added almost 15% in revenue per test because we were now getting eligibility correct and being able to do it very rapidly." Ken Kubisty, VP of Revenue Cycle, Exact Sciences Key AI technologies driving RCM transformation Healthcare revenue cycle managers have long trusted automation to handle repetitive tasks. Hesitancy around AI may stem from a lack of familiarity with its more advanced capabilities. Findings from the State of Claims survey reveal a widening comfort gap, with the number of respondents feeling confident in their understanding of AI dropping from 68% in 2022 to 28% in 2024. So, what are some of the key technologies providers should understand to help bridge the gap? While automation relies on straightforward, rule-based processes to handle repetitive tasks, AI tools are capable of learning, adapting and making decisions. A few examples to be aware of include: Machine learning: Analyses historical data to predict trends like claim denials and payment delays, and use this knowledge to prevent future issues Natural language processing: Extracts actionable insights from unstructured data, such as clinical notes and patient communications, giving staff consistently formatted data to use in RCM activities AI-powered robotic process automation: Goes beyond basic automation to handle decision-based workflows with precision, for example, in evaluating claims information to make predictions about the likelihood of reimbursement. Challenges and considerations in implementing AI in RCM Getting to grips with what AI technologies offer is an important first step for healthcare revenue cycle managers. However, successful implementation also calls for consideration of the practical challenges. Can AI solutions be successfully integrated with existing legacy systems? Will the data available be of high enough quality to drive meaningful insights? Are the costs of implementation within budget, especially for smaller providers? Is the workforce ready to buy into AI, or will extensive training be needed? With careful planning and a trusted vendor, these challenges are manageable. Embracing AI for a smarter, more efficient RCM The benefits of AI in revenue cycle management are clear: more innovative, faster processes that free up staff time and reduce errors, resulting in much-needed financial gains. To maximize AI, providers should begin by reviewing their organization's key performance indicators and identifying areas where AI can add the most value. This should focus on points in the revenue cycle where large volumes of data are being processed, such as claims submissions or patient billing, which are common areas for inefficiencies and errors. By taking a strategic, targeted approach, providers can find the right AI solutions to make the biggest impact – whether it's through curating patient insurance information, improving claim accuracy or predicting denials. A trusted vendor like Experian Health can guide teams through the AI setup and make sure it meets their needs. Find out more about how Experian Health helps healthcare providers use AI to solve the most pressing issues in revenue cycle management. Learn more Contact us

Collecting patient payments is an ongoing struggle. Bills are confusing, reminders go missed and patients can't always afford to pay. Rising self-pay costs, new medical debt mitigation regulations, Medicaid changes and staff shortages all put added pressure on billing teams. The result is often poor patient financial experiences, wasted staff time and bad debt. As revenue cycle managers figure out a path forward in today's complex – and costly – healthcare environment, analytics-based collections optimization could be the answer. Solutions like Collection Optimization Manager help providers quickly understand a patient's ability and willingness to pay with screening and segmentation models, identify charity eligibility and implement effective patient billing outreach plans. This article summarizes a recent webinar with two longtime users, Wendi Cardwell of Novant Health and Wanda Taylor of Cone Health, who have successfully partnered with Experian Health to streamline collections, increase self-pay revenue and humanize patient financial experiences through segmentation and automation. How collections optimization boosts revenue Cari Cesaro-Hoffman, Senior Director–Enterprise Consultant for Collections Optimization Manager at Experian Health, set the stage with observations on how collections optimization solutions, like segmentation and automation, help providers maximize collections and engage patients compassionately. “Segmentation is the driver of successful patient billing cycles. It guides the team to focus on collections with those patients or guarantors with a higher likelihood to pay while helping to create patient-centric, positive patient financial experiences. Automation and customized operational processes embedded within collections optimization enhance the process even further.” Having the right collections optimization partner is critical. Both Cardwell and Taylor agree that Experian Health's unique consultative approach and comprehensive technology have been key to their success. The technology integrates seamlessly with account receivable data, helps streamline collections processes and allows for quick pivots to meet ongoing regulation changes — all while adding humanization to the revenue cycle. How to optimize collections with patient-centric insights In collections optimization, segmentation and automation allow healthcare organizations to evolve their payment collection strategies to keep up with rising healthcare costs, meet new industry regulations and drive more self-pay revenue. By using sophisticated, patient-centric insights, providers can make informed decisions on which accounts to prioritize, write off or refer to collection agencies. Collections optimization solutions, like Experian Health's Collection Optimization Manager, use multiple data sources to automatically screen and segment accounts based on propensity-to-pay scores. With a better understanding of each patient's financial situation, staff can prioritize high-value accounts and increase collections revenue. Experian Health's collections consultants provide ongoing support and expert advice, while advanced reporting allows revenue cycle managers to easily benchmark performance, refine patient payment forecasts and manage bad debt. Patient collections processes can be further optimized by integrating complementary financial screening and patient engagement tools, like Patient Financial Clearance, PatientDial and PatientText. Key takeaways from 2 real-world examples of successful collection optimization Cardwell and Taylor share how they are using collections optimization to boost revenue in today's increasingly high-cost healthcare environment. Below are the key takeaways from their conversation about how segmentation and automation are helping streamline collections, improve the patient experience and meet ever-evolving regulations. Segmentation and automation improve collections performance Segmentation and automation drive the patient billing cycle and enhance collection efforts – especially for self-pay collections. With the help of Experian Health's Collections Optimization Manager, Novant Health and Cone Health are able to quickly identify those patients likely to pay their bills and implement patient-first collection strategies. Cardwell shares how segmentation helps personalize the patient collections experience. "If patients have a high propensity to pay their bill and it's a low balance, like $300, they may not need a call quite yet since they may immediately make a payment when they get their bill. But if it's a high propensity to pay their bill and it's $3,000, they may be sitting at home wondering, 'How am I going to do this?' So, they just need that little nudge by someone calling and saying, 'Did you know we have payment plans that are interest-free? Let's help you get set up on that.'" Taylor agrees, "The automation is just remarkable for the ability to give our patients that white glove treatment and to be able to either contact them in some way, talk to people that want to talk to us or offer the automation that others want." Cardwell and Taylor also note that collections optimization helps their billing teams easily integrate charity care and financial assistance processes more closely with collections and revenue cycle workflows. This allows both organizations to quickly adapt to industry changes and new requirements, like medical debt mitigation regulations. Optimizing collections delivers real-world results The successful implementation of Collections Optimization Manager for Novant Health and Cone Health serves as a model for other healthcare organizations looking to improve their collections and revenue cycle performance. To date, Novant Health has seen an impressive ROI of 9.5/1 with a $16 million combined lift across hospital billing and provider billing, while Cone Health cleared $14M in patient payments and a 6:1 ROI. Additionally, Caldwell and Taylor both report saving valuable staff time and resources. Automating some of the screening processes and routing through bankruptcy, deceased and return mail has resulted in more than 3,000 manual hours saved between the two organizations. Caldwell says working with Experian Health reduces IT hours, especially for organizations that outsource IT like Novant Health. For example, “If you decide you no longer need to use a particular vendor partner and need to send data to another vendor partner, Experian Health can quickly make that flip for you.” Successful automated call campaigns driven by segmentation have been another win. Taylor describes using segmentation to efficiently “run unattended call campaigns that push calls out to patients with payment plan reminders.” Caldwell agrees, and shares that Novant Health has seen similar successes with collections call campaigns. Novant Health is using the data to run automated Medicaid enrollment call campaigns and is “looking into doing mother-baby” call campaigns to remind new moms to enroll their newborns for insurance coverage. Choosing the right collections optimization partner matters For providers looking to evolve their collections strategies, both Cardwell and Taylor stress the value of working with a collections optimization partner that offers turnkey solutions for a positive patient financial experience, seamless data integration and up-to-the-minute regulatory knowledge. Cone Health first adopted Coverage Discovery® and ClaimSource® before adding Collections Optimization Manager and Taylor says, “It just came together seamlessly. We've successfully evolved those products into a multi-item suite of information that is seamless in passing information back and forth. Experian Health also has their ear to what's happening at the state level and in federal and regulatory matters. So anytime there are new things coming down that impact our functionalities, they are coming to us with solutions to keep us cutting-edge.” Cardwell elaborates on how collections optimization helps Novant Health foster a human-centric financial experience. She says, “When we look at engaging our communities, Collections Optimization Manager has enabled us to do that effectively and efficiently, allowing us to deliver on our brand promise to care for our patients, each other and our communities.” The future of collections cycle management is here Healthcare organizations are already making strides to adopt collections optimization strategies that improve patient collection rates and boost self–pay collections. In today's fast-changing healthcare environment, it's critical for revenue cycle managers to evolve collections strategies to keep pace with patient needs and regulatory requirements. Working with a partner like Experian Health can help healthcare organizations better fulfill their financial goals, meet the needs of the patient population and deliver positive patient financial experiences. Find out more about how Collections Optimization Manager is changing the future of healthcare collections and watch the webinar to hear the full conversation on 'Boost self-pay collections: Novant Health & Cone Health's 7:1 ROI & $14M patient collections success.' Learn more Contact us

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

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

The denial challenge is getting tougher. In Experian Health's latest State of Claims 2024 survey, almost three-quarters of healthcare administrators agree that claim denials are increasing. The majority also agree that difficulties with claims—like reimbursement times, errors, and payer policy changes—are becoming more common. It's no surprise that denial prevention is a priority for 84% of respondents. However, many organizations still focus on reactive strategies, like working harder with denial management teams or appealing claims once the denial comes through. These efforts have their place, but they only address the problem after it occurs. It's a time-consuming, costly and ultimately inefficient way to face the denial challenge overall. A better approach is to figure out how to prevent claim denials in the first place. This article looks at how to build a proactive denial prevention strategy using automation and artificial intelligence (AI), to streamline claims processing and nip denials in the bud. Understanding denial prevention in healthcare Preventing denials starts with understanding the “ins and outs” of the claims process, particularly payer requirements. Denials occur when a payer refuses to reimburse a provider for services rendered, often due to avoidable coding errors, missing documentation or procedural mistakes. When that happens, providers are left to rework the submission or look elsewhere – most likely to the patient – to fill the funding gap. Many are simply written off to bad debt. To avoid receiving an 835 file with the dreaded claim denial notice, providers must focus on the root causes of denials and get ahead of the pitfalls. The importance of claim denial prevention With denial rates exceeding pre-pandemic levels, 42% of survey respondents say the economy and declining consumer confidence make payer reimbursements more urgent. While financial stability is the obvious driver for getting claims right the first time, denial prevention also improves operational efficiency and reduces the billing and coding staff workload. Denials are frustrating for patients and staff. When claims are processed correctly the first time, providers avoid delays and billing complications and reduce patient stress over unexpected costs. Preventing denials is critical for maintaining trust and ensuring patients feel secure about their financial obligations. How to prevent claim denials Denial prevention strategies should start with addressing the underlying causes of denials. Here are five denial prevention strategies to consider: 1. Improve data accuracy from the start Garbage in, garbage out. If patient information, insurance eligibility, prior authorizations and billing codes are input incorrectly or missing altogether, providers will continue to submit error-filled claims that have no hope of being paid. Tools like Patient Access Curator can verify relevant data for accuracy before claim submission and reduce the risk of denial. 2. Use AI and automation for efficiency If there was ever a case for using automation and artificial intelligence, it's in claim denial prevention. However, around half of providers are still using manual processes, leaving them playing catch-up to the payers who are already using AI to work at scale. Only 10% have automated the process, using AI to correct and resubmit claims. Tools like ClaimSource® can automate eligibility verification and coding, perform error checks before submissions and ensure claims meet payer requirements instantly. This cuts the time and effort wasted on manual processes, releasing staff to focus on activities that need human attention. 3. Automate pre-claim scrubbing to catch errors A great use case for automation is in providing an extra pair of eyes to pore over claims and catch common errors like missing data and wrong codes before submission. Experian Health's Claim Scrubber analyzes claims line by line to ensure that claims are submitted to payers and clearinghouses without errors, increase first-time pass rates and prevent rebilling. 4. Track performance for ongoing improvement Every denial prevention strategy should include monitoring and reporting. Tools that offer real-time tracking of key performance indicators such as denial rates, clean claim percentages, resubmission times, and the reasons for denials can help staff identify patterns. With these insights, they'll have complete visibility into any recurring problems clogging up their claims processes. 5. Outsource to a trusted vendor for extra support and expertise Finally, providers might consider outsourcing denial prevention to a specialist vendor who can help them develop the right strategy and toolkit to streamline billing, improve data integrity and manage claims to ease pressure on internal resources. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Proactively reducing claim denials These strategies raise an important question: can existing revenue cycle technology handle the increasing volume of denials? Healthcare administrators aren't convinced: only 54% of survey respondents feel their organization's technology is sufficient to meet demand, down 23 percentage points since 2022. To implement these denial prevention strategies effectively, providers may need to consider upgrading their toolkit rather than relying on traditional systems. Experian Health offers two AI-powered solutions that help providers better predict and prevent denials: Prevent denials with Patient Access Curator  Too many denials originate in patient access, so prevention must start here. Patient Access Curator uses AI-driven data capture technology to verify patient details quickly and accurately. With a single click, PAC can automatically check eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, coverage discovery and financial status. Running multiple manual queries is a thing of the past, saving staff hours and propagating clean data throughout the entire revenue cycle. Watch the webinar to learn more about how Patient Access Curator helps prevent denials with accurate data from the start. Predict denials with AI AdvantageTM Clean data sets the stage for denial prevention, but AI adds an extra layer of protection by forecasting potential issues before it's too late. AI AdvantageTM does this in two ways. First, the Predictive Denials component analyzes claims using the provider's own ClaimSource® data and alerts staff to high-risk claims so errors, inconsistencies or missing documentation can be corrected before submission. Next, the Denial Triage component prevents missed revenue opportunities by segmenting denials and guiding staff to those worth reworking. See how AI Advantage works: If providers can't prevent denials, they can't protect their bottom line. With the right data analytics, automation and AI, providers can take control and spot issues before they become problems instead of spinning their wheels in endless rework. With more advanced tech on their side, it's possible to close the gap with payers and prevent denials, but it also gives staff the headspace to focus on patient care and support. Find out more about how Experian Health's Claims Management solutions help providers build effective denial prevention strategies and reduce lost revenue. Learn more Contact us

According to a new report by the American Hospital Association, administrative costs now make up over 40% of total hospital expenses. Hospitals and health systems spend around $40 billion annually on billing and collections alone. For revenue cycle managers, the pressure is building as administrative tasks like insurance eligibility verification, claims management and payment processing overwhelm their teams and drain budgets. However, a sizeable chunk of these costs—perhaps as much as $18.3 billion—could remain in hospitals' hands if certain administrative tasks were automated. Automating key revenue cycle management (RCM) workflows improves efficiency, accuracy and cash flow, while easing staff stress and expediting patient care. Could it be the secret weapon to alleviating administrative burdens? This article looks at the issues in further detail, and explores 5 use cases that show how automation can reduce administrative costs in healthcare. Understanding administrative costs in healthcare Spending on healthcare administration in the U.S. has risen from $654 per person in 2013 to $925 in 2021. Administrative costs cover the resources needed to manage the non-clinical aspects of care. These resource requirements are immense in a complex system with multiple payers, fragmented data systems and growing regulatory demands. Add persistent staffing shortages and increasing patient volumes to the mix, and it's easy to see how costs spiral out of control – especially when relying on inefficient systems. The billions of dollars and hours of staff time consumed by administrative tasks make it clear that resources are not being used most effectively. This is where automation can make a difference. The role of automation in healthcare Automation reduces human errors, speeds up workflows and accelerates cash flow. It frees up time, money and headspace to optimize services and improve patient experiences. It's no wonder it's gaining traction in revenue cycle management. However, many providers are not fully capitalizing on automation's potential: Experian Health's latest State of Claims 2024 report shows that fewer healthcare administrators feel their organization's technology is sufficient to meet RCM demands compared to two years ago. How can they tap into the benefits of automation to reduce administrative costs? Benefits of automation and how it can reduce administrative costs in healthcare Automating healthcare administration is about doing more – and better – with less. Some of the benefits include: Fewer errors in billing, coding and claims management. Fewer mistakes mean fewer denials, which translates to faster payments and less rework. Reducing time to get paid, as automated processes speed up claim submissions, insurance verification and payment collections. Cash flow improves and staff spend less time chasing payments. Alleviating staffing shortages, as automation takes care of repetitive tasks like data entry, payment reminders and reporting. Management can reduce the burden on overworked staff and curb training costs, while teams can focus on “value-added” work. Improving efficiency in every corner of the revenue cycle. Automating routine tasks makes the entire billing and revenue cycle process more efficient, allowing teams to handle more work in less time without increasing headcount. Happier patients (and a better-looking bottom line). Automation makes it easier for patients to understand their bills, set up payment plans and pay their balances online. Satisfied patients are more likely to pay on time, reducing the cost of chasing overdue payments. Implementing automation in healthcare When it comes to reducing administrative costs, selecting the right parts of the workflow to automate is key. Here are five possible use cases to consider: 1. Streamline insurance eligibility checks “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.” This is what one patient at Providence Health said, after the health system switched to automated insurance eligibility verification. Insurance Eligibility Verification connects to over 900 payers and automatically checks patients' coverage and plan-specific benefits information in real-time. This reduces the manual effort required by staff and prevents the delays and denials that lead to additional administrative costs. As the patient notes, it means patients get early clarity about how their care will be funded, so there are no surprises later. Read the case study: How Providence Health found $30M in coverage and reduced denials with automated eligibility checks. 2. Automate claims submission More than half of healthcare administrators say that claims errors are increasing. A quick win would be to use automation to pre-fill patient data and avoid the inconsistencies and typos that occur with manual input. A more significant gain could come from combining multiple automations to populate, check and track claims submissions. Tools like ClaimSource® can automate the entire claims cycle in a single application. Indiana University Health (IU) utilized ClaimSource to process $632 million in claims transmissions in just one week, after a halt to their operations. Summit Medical Group paired Claim Scrubber with Enhanced Claims Status to improve claims submission. Claim Scrubber ensures all claims are complete and accurate before being sent to the payer, and generates alerts so staff can intervene quickly if an error pops up. Enhanced Claim Status automatically pings payers for status requests so staff can spend less time seeking updates and accelerate follow-up activities. With this approach, Summit boosted their first-time pass-through rate to 92% and reduced accounts receivable days by 15%. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more 3. Improve denial management Denials remain one of the biggest pain points for providers. Payers are miles ahead in their use of automation and artificial intelligence (AI), using sophisticated machine learning tools to process and deny claims at scale. Experian Health's flagship AI-powered denial management solution, AI AdvantageTM, can help close the gap. This tool “learns” from an organization's historical claims data and trends in payer behavior to predict the probability of denial. It also identifies and segments denials so staff can prioritize those with the highest chance of being reimbursed, reducing the time and cost of manual appeals and rework. 4. Accelerate patient payments On the patient side, automation can be deployed to send patients reminders about outstanding balances, set up payment plans and process payments quickly and securely. Simplifying patient billing makes it easier for patients to pay, which increases collections rates while reducing the need for follow-up calls. Read more: 5 ways patient payment software improves patient satisfaction 5. Generate better financial reports Another smart use case for automation is generating real-time revenue cycle performance reports. With advanced data and analytics, staff no longer need to spend hours compiling information, while managers get faster, reliable information to inform strategic decisions. Experian Health's healthcare data analytics turns raw data into business-ready information to find potential sources of revenue leakage and boost financial performance. The future of healthcare automation Automation is already helping reduce administrative costs in healthcare by relieving staff of the tedious, time-consuming, repetitive tasks that drain time and money. However, many still rely on old data systems that don't work well together, leaving revenue opportunities slipping between the cracks. Choosing solutions that improve integration and interoperability will continue improving data-sharing between platforms and services, further reducing errors and delays. Looking ahead, automation and AI will play an increasingly major role in handling complex tasks in revenue cycle management. RCM leaders will find even more opportunities to minimize manual intervention and lower administrative overheads as these tools evolve. Learn more about how Experian Health's automated Revenue Cycle Management solutions help reduce administrative costs in healthcare and create more resilient revenue cycles. Learn more Contact us

Claim denials are a well-documented challenge for healthcare organizations. Denied claims take much longer to pay out than first-time claims, if they get paid at all. Each one means additional hours of rework and follow-up, pulling in extra resources as staff review payer policies and figure out what went wrong. It's time-consuming and costly. Beyond dollars and paperwork, denials affect patient care as uncertainty about payments leads to delays in treatment or unexpected out-of-pocket costs. But how do healthcare leaders feel about the state of claims management today? How are they tackling the administrative burden? Is there any light at the end of the denials tunnel?   Experian Health surveyed 210 healthcare revenue cycle leaders to find out. The 2024 State of Claims report breaks down the survey findings, including insights into how automated claims technology is being used (or not!) to optimize the claims process and bring in more revenue. What is the current denial rate for healthcare claims? 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of rework and lost revenue that providers were counting on. In 2009, claims processing accounted for around $210 billion in “wasted” healthcare dollars in the US. A decade later, the bill had climbed to $265 billion. Industry reports—including Experian Health's State of Claims series—repeatedly observed a rise in denial rates. Today, 73% of providers agree that claim denials are increasing, while 67% feel it's taking longer to get paid. Providers constantly worry about who will pay – and when. What are the most common reasons for healthcare claim denials? According to the State of Claim survey respondents, the top three reasons for denials are missing or inaccurate data, authorizations, inaccurate or incomplete patient info. In short? The problem is bad data. Given how much information has to be processed and organized to fill out a single claim, this isn't surprising. From patient information to changing payer rules, the sheer volume of data points to be collated creates too many opportunities for errors and omissions. On top of that, the rules are always changing. More than three-quarters of providers say payer policy changes are occurring more frequently than in previous years, making it increasingly difficult to keep up. Other challenges, such as coding errors, staff shortages, missing coverage and late submissions still play a role, but it's clear that solving the data problem could make a meaningful dent in the denials problem. Read the blog: How data and analytics in healthcare can maximize revenue Could automation improve claim denial statistics? To help end the cycle of denials, more healthcare providers are turning to claims management software to resolve or prevent the snags that interfere with claims processing and billing workflows and boost claim success rates. That said, around half of providers still review claims manually. Despite the proven benefits of integrated workflows and automation, the drive to implement new technology during the pandemic seems to have lost momentum: the number of providers currently using some form of automation and/or artificial intelligence (AI) has dropped from 62% in 2022 to 31% in 2024. Could this be down to a lack of comfort with how new technologies work? Only 28% feel confident in their understanding of automation, machine learning and AI, compared to 68% in 2022. For those who are curious but cautious, here are a few ways claims automation can help improve claim denial statistics: Connect the entire claims process end-to-end: Using an automated, scalable claims management system like ClaimSource® helps providers manage the entire claims cycle in a single application. From importing claims files for faster processing to automatically formatting and submitting claims to payers, it simplifies the claims editing and submission process to boost productivity. Submit more accurate claims: 65% of survey respondents say submitting clean claims is more challenging now than before the pandemic. There's a strong case, then, for using an automated claim scrubbing tool to reduce errors. Claim Scrubber reviews pre-billed claims line by line so errors are caught and corrected before being submitted to the payer, resulting in fewer undercharges and denials and better use of staff time. Improve cash flow: Automating claim status monitoring is one way to accelerate claims processing and time to payment. Enhanced Claim Status eliminates manual follow-up so staff can process pended, returned-to-provider, denied, or zero-pay transactions as quickly as possible. Eliminate manual processes: While there are some tasks that genuinely need a human touch, too much staff time is wasted on repetitive, process-driven activities that would be better handled through automation. Denials Workflow Manager automates the denial process to eliminate the need for manual reviews. It helps staff identify denied claims that can be resubmitted and tracks the root causes of denials to identify trends and improve performance. It also integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so staff can view claim and denial information on a single screen. Experian Health was client-rated #1 by Black Book™ '24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Improving claim denial statistics with AI While automation speeds up the denials workflow by taking care of data entry, AI can look at that data and recommend next steps. Current ClaimSource users can now level up their entire claims management system with AI AdvantageTM, which interprets historical claims data and payer behavior to predict and prevent denials. The video below gives a handy walk-through of how AI Advantage's two offerings, Predict Denials and Denial Triage, can help providers respond to the growing challenge of denials: As the survey shows, there's a growing need for easy-to-implement solutions to the denials challenge. While progress has been made, the findings suggest there's still room to use automation and AI more to prevent denials and level the playing field with payers. Download Experian Health's 2024 State of Claims report for an inside look at the latest claim denial statistics and industry attitudes to claims and denials management. Get the report Contact us

Reimbursement issues in the healthcare industry are complex, but reimbursement is essential for healthcare organizations. Proper reimbursement allows providers to run operations efficiently and deliver consistent, high-quality patient care. It also enables organizations to invest in technologies that advance their operations. Read on to learn more about the causes of reimbursement issues and discover the strategies, tools and automated solutions healthcare providers can use to address them. Understanding reimbursement issues in healthcare Healthcare organizations often provide care without upfront payment and hope that healthcare payers will fulfill their obligations and settle their bills. This system impacts all healthcare stakeholders and influences the quality and timeliness of patient care. It also affects staff productivity, satisfaction, hospital operational efficiency, cash flow and bottom line. However, the reimbursement system is also fraught with long-standing challenges that complicate financial growth for healthcare organizations. Claim denials, changing reimbursement landscape and payer rules, prior authorization hurdles and staffing shortages complicate reimbursement issues in healthcare and cost hospitals billions of dollars in administrative complexities. Key challenges of healthcare reimbursement concepts Key challenges that fuel reimbursement issues and impact hospital cash flow include: High patient volumes and submission of inaccurate claims Complex payer policies, compliance issues and poor communication in payer-provider partnerships Increasing claims denials leading to nonpayment Staff shortages and lack of training Slow adoption of data, analytics and automation solutions Causes of reimbursement issues By identifying the causes of reimbursement issues that result in delays and nonpayments, healthcare organizations can develop effective strategies to tackle them. Here is a closer look at why reimbursement issues commonly occur: Rising claim denials Claim denials lead to delayed or lost reimbursements, which amount to millions of dollars in lost revenue for hospitals. The Journal of AHIMA reports that claim denials cost hospitals $5 million, annually. According to Experian Health's State of Claims report, 38% of healthcare providers experience claims being denied 10% of the time, or more. 67% of respondents also agreed that reimbursement times are increasing. A report from the American Hospital Association noted that Medicare Advantage plan payment denials increased by 56% for the average health system between January 2022 and June 2023. These denials led to a 28% decline in cash reserves—even as maintenance expenses rose by 90% and other operational costs increased by up to 35%. With increasing claim denials, rising operational costs and a drop in cash reserves, revenue cycle leaders are under pressure to address costly claim denials. Staffing shortages and lack of appropriate training Challenges with staffing shortages and inadequately trained staff to handle revenue cycle management processes can lead to reimbursement issues for healthcare organizations. New research, published daily, shows that healthcare organizations are grappling with staffing shortages and the associated consequences. Experian Health's recent survey, Short Staffed for the Long-Term, identified staffing shortages as being strongly linked with increasing claims denial and declining reimbursement rates in healthcare. In fact, nearly all survey respondents noted that staff shortages have affected their organization's revenue opportunities. According to 70% of the survey respondents, staff shortages are seriously impeding payer reimbursement, and 83% report that it has become increasingly challenging to follow up on late payments or provide assistance to patients facing financial difficulties. In another Experian Health survey, The State of Patient Access, 2023: The Digital Front Door, 87% of providers report that healthcare staffing shortages are worsening healthcare access. Additionally, inadequate and lack of up-to-date training in handling medical coding, eligibility verification, patient estimates and other necessary administrative processes for preparing and submitting clean claims and receiving reimbursement hamper the efficiency of existing staff. Complex prior authorization process When healthcare organizations fail to obtain prior authorization in cases where it is needed, they can inadvertently face healthcare reimbursement issues. Prior authorization is a cost-control mechanism used by payers to confirm the justification for costly healthcare services. When prior authorization is required, providers must receive approval from payers before their services can be eligible for reimbursement. Prior authorization is a heavy and time-consuming administrative burden. According to the 2023 AMA prior authorization survey, every healthcare physician completes 43 prior authorizations per week on average—a process that takes about 12 hours. Worse, more than a quarter of providers report that prior authorizations are often or always denied. The complex prior authorization process leads to treatment delays, abandonment and reimbursement hassles. Many denials occur after patients have already started receiving care, or or when required care is only partially covered, causing further challenges. Changing reimbursement policies and payer rules Healthcare providers unintentionally fall behind in staying updated on critical reimbursement policies. The reasons vary, but typically include shifts in the reimbursement landscape, inconsistencies in payer rules, unannounced rule changes and poor communication in payer-provider relationships. Complex and ever-evolving payer policies also result in substantial losses for hospitals. Hospital revenue and resources, staff productivity and satisfaction and patient experience all bear the brunt. Hospitals relying on manual processes instead of automated software solutions to manage reimbursement hurdles are often hit even harder. Strategies to resolve healthcare reimbursement issues Organizations working to achieve impactful reimbursements can adopt strategies for success, including: Adopt AI and automation to prevent claim denials In the State of Claims 2024 report, only 31% of providers reported using some form of automation and/or AI technology. Automated solutions provide a time-and-resource-efficient approach for healthcare organizations to streamline claims and revenue cycle management. For example, ClaimSource® is a single software solution used to automate the claims management process and improve reimbursement rates. This solution automates tasks crucial to claims approval and reimbursements, like eligibility verification and coding, making the process faster and error-free. Experian Health's AI Advantage™ is a prime example of an AI-powered solution that works seamlessly with automation solutions to provide organizations with the greatest potential for reimbursement. It offers a two-in-one avenue relevant before claims submission and after claims denial. Organizations can reduce denial rates with Predictive Denials and predict high-value denials that improve reimbursement rates with Denials Triage. Implementing AI and automation can help strengthen financial performance and increase reimbursement rates for healthcare organizations. When integrated with AI-powered solutions that provide prediction and accuracy, automation takes the claims management burden off the shoulders of overworked staff. Staff can then redirect their efforts towards activities that enhance patient experience, care quality and outcomes. Automate prior authorizations Prior authorizations can be time-consuming and expensive, especially with manual, error-prone systems. According to a paper published in the Journal of Perspectives in Health Information Management, 85% of providers consider the burden associated with prior authorization to be “high or extremely high.” Yet, many providers still rely on manual processes, which further complicate prior authorizations and create stumbling blocks to getting reimbursements. Instead, healthcare organizations can embrace automated solutions, like Experian Health's Prior Authorizations solution, to streamline this process. This solution automates the prior authorization inquiry and submission process and helps providers achieve prompt payments, ultimately ensuring predictable revenue cycles. By adopting automation, they save staff time and improve operational efficiency, which also improves care delivery and elevates the patient care experience. Equip staff with technology solutions Healthcare billing teams can also effectively tackle critical aspects that increase the potential of securing reimbursements using technology solutions designed to help boost productivity without increasing headcount. These include: Denial Workflow Manager to eliminate the need for manual review of claims status and remittance advice, resulting in reduced denials Enhanced Claim Status eliminates manual follow-up tasks and lets providers respond early and accurately to pended, returned-to-provider, denied, or zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed Patient Payment Estimates to provide better price transparency so patients are empowered to make better decisions and healthcare providers get paid faster Overcoming reimbursement issues for better healthcare outcomes Reimbursement issues pose many challenges for today's healthcare organizations. They burden hospitals with excessive administrative work, cause delays in healthcare delivery and put the patient experience in the backseat. They also impact healthcare provider satisfaction and productivity and worsen hospital financial performance. Empowering staff with automated solutions enables them to swiftly and accurately manage the different fragments leading to reimbursement. This can result in improved healthcare outcomes and organizational profitability. Learn more about how Experian Health's Claims Management and Clearinghouse solutions (ranked #1 Best in KLAS 2024) can help organizations secure reimbursements that boost their bottom lines. Get reimbursed faster Contact us

Despite increased access to claims management technology, claims denials are still on the rise in 2024. Contributing factors include growing healthcare costs, stricter payer reimbursement policies, and claims processing errors. Providers are seeing an uptick in nonpayment, plus an added burden on administrative staff, disrupted patient care, and hits to the bottom line. Experian Health surveyed over 200 healthcare professionals, primarily in executive or management roles, to better understand the current state of claims. The findings of the State of Claims 2024 report break down the latest health insurance claim denial statistics, reasons for denials, and providers' concerns about reimbursement. Rising healthcare costs: who will foot the bill? The U.S. healthcare system is the most expensive in the world, and costs continue to rise. In 2022, healthcare spending reached $4.5 trillion, a threefold increase from $1.4 trillion in 2000. In 2023, costs rose 7.5% to $4.8 trillion. Paying for healthcare is becoming more and more out of reach for patients and causing great concern. Over three-quarters (77%) of providers worry patients will skip out on their medical bills. Payer reimbursement challenges are also weighing heavily on healthcare leaders' minds. More than 75% are worried about nonpayment due to ever-evolving payer policy changes. They also have concerns about the pre-authorization struggles that have continued since 2022, as reported in the State of Claims 2022 survey. Hospitals are particularly feeling the financial pinch of operating within such an expensive environment and face uncertainties about meeting financial obligations on top of other major post-pandemic challenges like staff shortages. The impact of claims denials Providers continue to see claims being denied in greater numbers. In 2022, 42% of respondents said denials are increasing. The number jumped to 77% in 2024. Similarly, the time it takes to be reimbursed is increasing, per 67% of respondents. That number was 51% in 2022. In 2024, 84% of healthcare organizations will make reducing denied claims a top priority. The Journal of Managed Care & Specialty Pharmacy reports that the burden of denied claims totals around $260 billion annually. The impact of claim denials is far-reaching, affecting the patient experience and revenue cycles. Struggles with claims also burden staff and drain resources, contributing to even more losses. The growing challenge of data collection, verification and authorization Successful claims processing depends on accuracy. However, achieving accuracy in data collection, verification, and authorization processes remains a continued challenge for claims management teams. Nearly half of respondents (46%) in the State of Claims 2024 report identified missing or inaccurate information as the primary cause for denial. Inaccurate or missing data also creates extra steps in claims processing, resulting in the need for secondary checks and “wasted” healthcare dollars. Survey respondents reported using multiple solutions to collect all the necessary patient data for claims, with some using as many as four different products. Leveling the playing field in claims management with technology Staying on top of reimbursement requirements and processes is complex, resource-demanding and time-consuming. Inaccuracies commonplace with manual processing exacerbate issues and further extend processing and reimbursement times. However, automation and AI technology have proven effective at reducing claims denials and the burden of manual processing. “Adding AI in claims processing cuts down denials significantly,” Tom Bonner, Principal Product Manager at Experian Health, explains. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction—AI is the tool hospitals need for better healthcare claims denial prevention and management.” During the pandemic, providers embraced new technology to meet immediate needs; however, that momentum slowed in recent years. In 2022, survey data revealed that 62% of providers were using some form of automation and AI technology. Yet, in 2024, only 31% said they used this type of technology. Here's how claims automation can help healthcare organizations improve claims success rates: Manage the entire claims process: Using an automated, scalable claims management system, like ClaimSource®, helps reduce denials and increase revenue. Providers can manage their entire claims cycle in a single application and ensure claims are clean before submission. Submit more accurate claims: An automated claims submission tool, like ClaimScrubber, helps identify errors that typically result in denials or underpayments before submission. This results in quicker payments, less time chasing aged accounts receivables, and improved cash flow. Eliminate manual processes: Providers that use Denials Workflow Manager can target claims that need attention immediately, managing denials more effectively and increasing reimbursements significantly. Improve cash flow: Enhanced Claim Status helps providers take an early-and-often approach to monitoring claim status in the adjudication process. It eliminates manual follow-up tasks, allowing providers to respond early and accurately to pended, returned-to-provider, denied or zero-pay transactions. Prevent denials: Experian Health's AI Advantage™, an AI-driven platform, uses an organization's own historical claims data, plus Experian Health's sophisticated knowledge of payer rules, to continuously learn and adapt to an ever-changing payer policy landscape. This technology helps providers better predict and prevent claims denials, focus on high-priority claims, and boost overall revenue. Adaptation of technology is likely on the rise with 45% of healthcare leaders planning to invest in automation in the next six months. Over the next year, these investments could pay off if claims denials start to decrease as a result, prompting more healthcare organizations to boost investments in claims management technology. Download the State of Claims 2024 report to get the latest health insurance claim denial statistics, or contact us to learn how Experian Health can help with better claims management. Get the report Claims management solutions