Tag: ClaimSource

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

“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.

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.

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.

The complexities of healthcare claims management are a widespread, costly issue. While the American Medical Association (AMA) blames prior-authorizations as the main cause, it's clear that hospitals struggle to collect on predicted revenues often for months after they provide the service. It's not a sustainable situation as the costs of care delivery increase, staffing shortages drive up labor overhead, and inflationary pressures stretch healthcare providers to their breaking point. There is no question the claims denial process is ripe for innovation – and that's where artificial intelligence (AI) comes in. A 2022 Experian Health survey shows over one-half of healthcare providers increasingly turn to AI-driven healthcare claims management software to reduce claim denials. Tom Bonner, Principal Product Manager at Experian Health, says, “Adding AI in claims processing cuts denials significantly. 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.” Common reasons for medical claim denials Revenue cycle leaders place healthcare claims management as their number one issue in 2023. Experian Health's survey showed the three most common reasons for medical claim denials were: Needs more data and analytics to identify submission issues. Manual claims processing and a lack of automation. Insufficient training for staff. The sheer volume of changes to CPT codes is another issue affecting HCM or healthcare claims management. Experian Health identified more than 100,000 payer policy changes from March 2020 to March 2022. These shifts necessitate a never-ending cyclic need to train new staff, increase the risk of claim rejections, and slow down manual workflows in healthcare claims denials management. How can healthcare providers improve claims processing and overcome these challenges? Real-life ROI with AI in claims processing AI in claims processing solves these and other common revenue cycle problems. This technology is the innovation healthcare providers need to reduce denials and increase cash flow. AI can help at every point in the revenue cycle continuum, from improving the accuracy of payer data upfront to ensuring a clean claim and even targeting denials that yield the highest return. What real-life lessons does AI in claims management teach healthcare providers? Experian Health's new AI-powered solution includes AI Advantage™ - Predictive Denials and AI Advantage™ - Denial Triage, which is geared towards helping healthcare organizations reduce claim denials. Within six months of using AI Advantage, Schneck Medical Center reduced denials by an average of 4.6% each month. Claim corrections that formerly took up to 15 minutes to correct cut to just under five minutes. Even smaller ambulatory clinics like Summit Medical Group Oregon benefit from automating healthcare claims management. After implementing Experian Health's claims management software, the provider saw an immediate reduction in claims denials. Today, they boast a 92 percent clean primary claims rate. These results are typical across healthcare organizations that implement AI in claims processing. But what does the software do to clean up the complexities of claims management processing? How to avoid claim denials with AI In 2022, Experian Health surveyed 200 revenue cycle leaders around the country and identified technology shortfalls as a significant contributor to claims denials: 62% reported they lacked the data analytics to identify submission issues. 61% said manual processes and a lack of automation were significant problems. 33% suggested their healthcare claims management software was outdated or inadequate. Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software. The benefits of these tools lie in their ability to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can also assist in identifying inaccurate claims, improving claims processing accuracy and revenue cycle management. By using automation and AI together, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Tom Bonner says, “AI in claims processing maximizes the benefits of automation for better claims processing, better customer experiences, and a better bottom line for healthcare providers.” How does healthcare claims denial management software work to improve the revenue cycle? AI identifies and prioritizes high-value claims after denial AI in claims processing goes beyond automating process-driven manual tasks. It also removes the guesswork from healthcare claims management. For example, staff is often left guessing which denied claims are the low-hanging fruit that they should process first. Staff must decide which denied claims have a higher likelihood of reimbursement and a higher dollar value to maximize their efficiency. Why would healthcare providers leave these high-value/high-return claims to a manual “best guess” estimation process? Yet that is standard operating procedure in most hospitals. AI in claims processing identifies and prioritizes high-value claims automatically. Experian Health's AI Advantage - Denial Triage goes to work when a claim is denied by identifying and intelligently segmenting denials based on potential value so that staff focuses on resubmissions with the most significant bottom line impact. This intelligent segmentation removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials. But the front-end work AI software completes during healthcare claims management may be even more valuable. AI can prevent claims denials from occurring at all. AI proactively stops claim denials from occurring AI Advantage - Predictive Denials uses AI to identify undocumented payer adjudication rules that may 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. Experian Health also has other automated solutions that help facilitate claims management. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software also generates accurate adjudication reports within 24 to 72 hours to speed reimbursement. ClaimSource ranked #1 in Best in KLAS 2023, precisely for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. AI optimizes the claims process Another Experian Health solution, Enhanced Claim Status improves cash flow by responding early and accurately to denied transactions. This solution uses RPA to give healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim denied. Speeds up the denials process. Automates manual claims follow-ups. Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims. Denials Workflow Manager integrates with the Enhanced Claim Status module to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. How to reduce claim denials with AI and Experian Health There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex on its own, but human error plays a large part in missed opportunities and lost revenue. With AI in healthcare claims management, the revenue cycle streamlines and transforms. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI healthcare claims management software offers provider organizations a way to achieve these goals. Contact Experian Health today to reduce claim denials and improve your claims management process with AI Advantage.

AI and automation could cut US healthcare spending by up to 10% – a promising figure for hospitals operating on razor-thin margins. Despite the potential for cost savings and revenue growth, investing in AI can seem risky while the technology feels relatively new. But as denial rates increase, staff shortages persist, and payers race ahead with their own AI-led efficiencies, investing in AI and automation could help healthcare providers increase efficiency and reduce manual workloads, while improving the patient experience. In a recent podcast interview, Johnathan Menard, VP of Analytics at Experian Health, talked to Andrew Brosnan of Omdia about how providers can use AI and automation in healthcare to reduce admin costs and tackle staff burnout, while maximizing the ROI on new technology. This article sums up the key takeaways. “AI and automation are gaining momentum in the healthcare revenue cycle, but there remains untapped potential” For healthcare leaders, maintaining the financial health of their organization is critical to serving their communities. Menard sees untapped potential to use AI to improve financial prospects by automating and eliminating administrative tasks within the revenue cycle: “There are many repetitive, tedious tasks involving large amounts of data that's already collected, and mostly structured and standardized. That can be organized and analyzed with AI to help improve efficiency and accuracy.” Automation is a well-established route to lowering manual workloads, increasing efficiencies and generating data for better decision-making. AI takes this a step further. For example, Experian Health's flagship AI platform, AI Advantage™, can parse an organization's data to identify and predict patterns in payer behavior. It translates this data into insights that help providers boost profitability and improve the staff and patient experience. Menard explains why claims management is a prime use case for AI: “Last year, the average denial rate was already above 11%. That's 1 in 10 patients potentially having to deal with uncertainty about who will pay the bill, when they should be focusing wellness. That's where we see Experian Health being able to lean in and drive value and change in the healthcare industry with AI.” “Cost is the biggest barrier to AI and automation adoption in healthcare – but can be offset with the right data” Despite the potential upside, healthcare still lags other industries when it comes to implementing AI. Menard says that workforce costs are the biggest barrier to adoption: “In healthcare, it's not just a matter of implementing the technology or solution, but also maintaining it on a yearly basis with talent. Organizations are going to have to recruit an AI-competent workforce.” He says that providers may struggle to offer competitive salaries to attract staff with this skillset, but there are other ways to offset cost concerns. One example is working with a trusted third-party vendor to choose the best-fit AI solution for their organization. These vendors can leverage economy of scale, data and lessons learned in other markets to help providers deliver new models of care: “At Experian Health, we have health data spanning eligibility and benefits, address, identity, claims remittance payments. We have insights on 300+ million consumers and 126 million households. We're able to offer providers one of the most holistic views of today's health care consumer. It gets really exciting when you think about partnering with providers to augment their capacity to deliver a different style of care.” “Providers need to make sure staff see the benefits of AI and automation” Menard notes that successful implementation of AI needs staff buy-in: “Providers need to make sure staff see the benefits of what this technology can bring. They must also make sure they give them the proper training on how to embrace these capabilities. They do not replace your job; they augment you to do more, or they allow you to focus on doing the right thing, not the right thing that needs their specific level of expertise.” AI Advantage is a prime example, reducing the admin burden for staff, who can then focus on higher priority tasks. The solution takes a two-pronged approach to help staff reduce claim denials and maximize reimbursement: AI Advantage – Predictive Denials synthesizes historical and real-time claims data and payer decisions to flag claims that are likely to be denied. This allows staff to intervene and make necessary amendments prior to submission. AI Advantage – Denial Triage performs a similar function for claims that do end up being denied. It helps staff eliminate time spent on low-value denials by guiding them resubmissions that are most likely to be reimbursed. Schneck Medical Center and Community Regional Medical Center (Fresno) are seeing the benefits of AI Advantage. Watch the on-demand webinar to hear about their results. Moving beyond proof of concept Menard acknowledges that providers need to feel confident in a tool's ability to deliver before they make an investment, especially if they are operating on single-digit margins: “You can't do that without the proof of concept. There are too many competing priorities, especially in the revenue cycle, and healthcare leaders need to be laser-focused and very confident in their decision-making.” In part, this is what Experian Health is looking to do with AI Advantage. By demonstrating the power of AI to reduce costs and alleviate staff pressures within claims management, it can act as a springboard for smarter automation across other revenue cycle operations. Menard believes that as AI adoption expands, it will become faster, easier and cheaper to develop solutions at scale: “That's why we built the AI Advantage platform – to launch other products in the future and solve other issues throughout the healthcare journey. We talked about automation, adoption and healthcare. To me, the best way to automate a process is to eliminate the need for it in the first place.” Find out more about how AI and automation in healthcare can reduce costs, prevent staff burnout and help providers prepare for future challenges.

Artificial intelligence (AI) is cropping up everywhere. But it's about to make an even bigger splash by revolutionizing how providers handle HCM (healthcare claims management). In healthcare, the claims process is a real source of frustration. Thirty-five percent of healthcare providers say they lose more than $50 million annually in denied claims. That's a lot of money lost for healthcare providers after care is delivered to their patients. As industry costs rise, healthcare claims management becomes an unsustainable financial drain for providers, who have no choice but to push these costs back to the patients they're trying to serve. Using AI for claims management has numerous benefits - and with denied claims on the rise, healthcare providers will need to incorporate this technology or risk leaving millions on the table. AI Advantage™, Experian Health's innovative predictive analytics software, uses AI in claims processing to help providers expedite reimbursement and improve cash flow. This software takes the unsolvable Gordian Knot that is U.S. claims reimbursement and untangles it for faster reimbursement, better cash flow, and less wasted time. Understanding AI in Healthcare Claims Management The odds are stacked against providers before the patient ever visits their practice. One patient claim can go through 20 or more checkpoints before the payer approves reimbursement. Denied claims are much less likely to be paid, and 89% of hospitals say denial rates are rising. An Experian Health survey said the three most common reasons for medical claim denials include: Missing or incomplete prior authorizations Failure to verify provider eligibility Inaccurate medical coding Without question, healthcare claims denial management must include better training for staff to file claims without error. Providers need accurate patient data upfront, with standardized verification processes at each step in the process.However, healthcare providers can reduce or completely avoid many common reasons for medical claim denials by using AI in claims processing. AI claims management software provides “teachable moments” for staff by sharing claims management errors at the front-end of processing before submission and possible rejection by the payer. Tom Bonner, Principal Product Manager at Experian Health, says, “Healthcare providers everywhere ask themselves: How can we reduce claims denials? But we have the technology to go even further. By using AI in claims processing, providers can avoid claims denials altogether by proactively spotting and correcting the human errors that slow down reimbursement before the claim is submitted to the payer.” Top Benefit of Using AI in Claims Processing - Providers Avoid Claims Denials AI and automation are the one-two punch providers need to improve healthcare claims processing. Using AI healthcare claims management software helps organizations avoid claim denials far upstream — before it occurs. AI Advantage - Predictive Denials is a preventative tool that proactively stops bad claims before they turn into costly denials. This AI-driven healthcare claims management software works in two key ways: By proactively identifying undocumented payer adjudication rules potentially resulting in denials. By identifying claims with a high likelihood of denial based on an organization's historical payment data. Schneck Medical Center improved their claims management processing by using AI Advantage - Predictive Denials to first identify error-prone claims. When the automated system spots the probability of a denial, it triggers an alert that routes the claim to an investigative biller. The AI carefully scrubs the claim, checking coding errors, authorization status, insurance eligibility, and more. Once the agent resolves these errors, they can successfully submit the claim to the payer. Using AI in claims processing leads to improved accuracy and fewer rejections for better revenue cycle management. After leveraging these tools for six months, Schneck Medical Center reduced denials by 4.6% on average per month. Benefit #2 - Healthcare Claims Management Software Speeds Denials Mitigation But what if a claim makes it through to the payer and they deny it? Denial management is a tedious, time-consuming process that impedes cash flow. AI Advantage - Denial Triage uses advanced algorithms to segment denials based on their potential value, allowing billers to focus first on high-value claims to maximize the revenue cycle and quickly reduce the denials queue. AI in reimbursement processing increases the speed of healthcare claims management to help staff identify and target the claims that need attention as quickly as possible without wasting time on low-value denials. By using automation and AI, healthcare providers gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Benefit #3 - AI Software Automates Reimbursement for Faster Payment Experian Health offers a streamlined series of standardized, automated tools to help with claims management. From registration, quality assurance, and eligibility on the front-end to claims processing and denials management on the back-end, Experian Health has full lifecycle solutions to prevent and mitigate reimbursement denials. The Experian Health intelligent ecosystem is a comprehensive solution to the untenable healthcare claims denials management process. These tools include: ClaimSource: Voted Best in KLAS Claims Management Clearinghouse 2023, this healthcare claims management software gives providers reimbursement visibility in real-time from one intelligent hub. This software helps providers handle the entire reimbursement cycle. The tool allows end-users to create custom work queues to manage claims more efficiently. It also automates claims, allowing the software to clean submissions before they send. Flagging features let billers know exactly what's wrong with a claim, so staff can repair the error. Ensuring clean claims lessens denials and improves cash flow. Claim Scrubber spots claim errors within 3 seconds, flagging the claim with an explanation of why it needs reworking. Intelligent algorithms identify undercharging to maximize payer-allowed amounts. For medical billers and coders, this tool quickly spots the root causes of claims denial, faster and more accurately than doing it by hand. Enhanced Claim Status connects billers quickly to denied, pending, returned-to-provider, or zero-pay transactions well before the EOB or Electronic Remittance Advice forms process. Instead of waiting 30- or 45 days to review a denied claim, this software lets teams see the problems online in real time. It's an immediacy that's been missing from both front- and back-end claims management processes, allowing real teaching moments for revenue cycle teams. Denials Workflow Manager: Eliminates manual processes and allows providers to optimize the claims process. Providers no longer review claims manually, instead using computer automation to optimize follow-up activities. Claims management teams can quickly identify and target the claims needing attention quickly. Powerful features leverage root cause analysis to identify trends leading to claims denials. These platforms easily integrate with existing practice management and electronic health record software. They work well together or ala carte to increase the accuracy of claims documentation to eliminate denials. A successful strategy for reducing claims denials starts with AI and automation software. Healthcare organizations can reduce the time spent processing rejections and improve A/R by flagging at-risk claims. Ultimately, healthcare claims management software solves the complexities inherent in these processes. Higher patient satisfaction and greater provider revenues are possible. Talk to Experian Health today to see AI in claims processing at work.