Tag: ClaimSource

Nearly three out of four healthcare leaders said reducing claims denials was their highest priority in  Experian Health's State of Claims Report. But knowing how to reduce claim denials is difficult. According to the survey, 62% of providers said they had insufficient access to data and analytics, and 61% lacked automation to meet the challenges of healthcare claims management. New and emerging artificial intelligence (AI) tools aim to help providers overcome these hurdles. Makenzie Smith, Product Manager at Experian Health, shares her thoughts on how providers can harness AI tools to predict, prevent, and prioritize claim denials for better results—and why preventing claim denials is so critical now. Q1: What is the challenge for revenue cycle teams, specifically when it comes to managing claims denials? “Revenue cycle teams that want to optimize claims processing have to respond to shifting payer behaviors, including major changes in the volume of denials,” says Smith. “Payers have been able to outpace providers in adopting new technologies, including AI. Payers are able process claims in a matter of seconds. For revenue cycle teams, that means receiving a large volume of denials all at once, which can be overwhelming.” At the same time, keeping up with policy changes is more than a full-time job. “You may have 20 different payers, each with multiple plans and policies that each have their own reimbursement or clinical guidelines,” says Smith. None of these policies are static: “They're constantly changing, which creates a huge challenge for providers.” Finally, maintaining enough staff to manage increased volume is an uphill battle. “The number of team members handling denials has not grown in a proportional way. Quite the opposite: They're being asked to do more with less. As providers continue to struggle with staffing imbalances, the challenge is not only having somebody to actually sit in these seats, but also managing the constant training and retraining that goes along with it.” Q2: Why is effective denial management so critical for providers' success?  “By one estimate, half of our country's hospitals are operating in the red,” says Smith. “Healthcare finance professionals are under incredible pressure to maintain or increase their operating margins. Meanwhile, Experian Health data shows that most organizations operate with an initial denial rate of 10% to 15%, and that rate is increasing year over year. “Effective denials prevention and management allow providers to get paid appropriately for services they've already provided,” Smith continues. “Optimizing revenue, improving cash flow, and maintaining expenses all stack up to provide meaningful financial resources providers can use on essential investments in staffing, physician recruitment and retention; capital equipment; and the expansion of services or service areas.” Providers that can't maintain healthy margins may be at risk for acquisition. “[Providers' viability is] put at risk daily because they must fight for every dollar from payers,” says Smith. Q3: How is Experian Health helping providers leverage AI tools and technology to start leveling up their denial management strategies? “Healthcare claims management technology solutions should be helping to bring providers up to speed,” Smith says. “Experian Health has released two products powered by a machine learning technical enablement layer to the market this year. Providers that use ClaimSource® to manage their claims can add AI Advantage™ tools to improve the way they manage claim denials. “AI Advantage - Predictive Denials uses AI and the provider's historical claim and remit data on the most probable reasons for medical claim denials to predict when claims will deny, in real-time, prior to claim submission. Billing teams can review denial predictions within their existing claim review workflows,” says Smith. “The design is incredible, allowing teams a seamless workflow integration with almost zero additional training.” “When denials do occur,” Smith continues, “AI Advantage - Denial Triage provides a predictive score based on the likelihood of recovery. Many denial follow-up teams prioritize working denials based on the highest charge amount. While that seems like a logical approach, there's a better way: segmenting by likelihood of recovery to drive priority and accelerate cash flow and recovery rates.” Q4: How is AI Advantage different from using human intelligence to predict and triage claim denials? “In some ways, it's quite similar,” Smith explains. “I was a director of billing for several years before I came to Experian Health. Often, one of the more senior billers would come to me and say, 'Hey, we're starting to see a trend with this payer, or with this denial reason code. We probably need to talk to our payer representative about this.' AI Advantage uses machine learning to identify these trends with greater speed and effectiveness, system-wide and in real-time. “Without this tool, one biller could see a denial happening twice and think nothing of it, while the biller sitting next to them is experiencing the same thing. This technology compiles all of this information together and identifies the holistic picture, so everyone benefits and trends don't go undetected.” Using AI in claims processing can make human teams more productive; it may help them feel empowered as well. Schneck Medical Center saw an average 4.6% monthly reduction in denials after six months of using AI Advantage. “Our people spend hours and hours on the phone with insurance companies fighting for dollars on claims we believe [are payable],” says Skylar Earley, Director of Patient Financial Services at Schneck. “Any leg up we can give our team members is a big, big deal.” Watch the webinar to hear from Eric Eckhart of Community Regional Medical (Fresno) and Skylar Earley of Schneck Medical Center as they discuss how their organizations use AI tools for claims management. Q5: What types of denials can providers expect to prevent, versus those that will continue to be denied? “Overall, the answer depends on a few things: an organization's healthcare claims denial management processes and ability to change on the one hand, and payer requirements on the other,” Smith says. “Too often, providers say they're just playing the game that payers put forward, simply so they can get paid what they are contractually owed.  As an industry, we cannot continue to accept this as the status quo. We'll find ourselves and our communities in a worse position to access healthcare.” Organizations that are willing to adopt new technology and be agile with their denial strategies can reduce their denial rates, even in a constantly changing environment. “I've seen the most success in denial prevention with eligibility, authorization, and technical billing categories,” says Smith. “But AI and machine learning are opening the door for new potential strategies that are more effective, more efficient, and more productive.” Q6: Clearly, claim denials affect providers, but patients also have a stake here. How do denied claims interfere with a positive patient experience? “There's definitely a patient impact,” says Smith. “Medical billing is already confusing, and a lot of people just don't understand their insurance to begin with. Add in potential denials and bills that seem to keep coming for months and months before getting resolved, and patients are bound to feel frustrated. Getting claims right on the first submission solves many of these issues up front. It reduces anxiety and makes for a much better patient experience overall.” Adding AI to the claims management toolkit Understanding how to avoid claim denials is a priority with good reason: Minimizing denials can improve revenue, lighten the burden on staff, and even help maintain a positive patient experience. Marginal changes make a difference: Smith notes that an increase in denied claims from 10% to 12% at an organization with $500 million in gross patient revenue represents a $2 million impact. Adding AI tools doesn't eliminate all the challenges of managing healthcare claims, but it does help equip providers for the current environment—and the future. Learn more about how AI Advantage can help providers prevent denials, improve the likelihood of reimbursements, and prioritize denied claims for reworking more efficiently and effectively.

Payers are using automation to adjudicate healthcare claims at scale, leaving providers struggling to keep up. One major insurer was found to have denied over 300,000 claims in two months, with each one taking an average of just 1.2 seconds. Providers that continue to rely on manual claims management methods will see their margins squeezed as the denials challenge grows. The future of healthcare claims management is here - and the answer lies in artificial intelligence (AI). Providers can level the playing field by turning to AI and automation , using tools like AI Advantage™ to streamline healthcare claims management. This article summarizes a recent webinar with two early adopters, Eric Eckhart of Community Regional Medical Center (Fresno) and Skylar Earley of Schneck Medical Center, who are using the technology to prevent denials and increase collections. Small increases in claim denials can lead to major revenue loss Makenzie Smith, Product Manager for AI Advantage at Experian Health, set the stage with observations on the current state of claims management. She notes that one of the biggest challenges when it comes to denials is constantly shifting payer behavior: “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.” Two hypothetical scenarios illustrate the potential impact of just a 2% increase in denials, assuming other variables remained constant: In an organization with a gross patient revenue (GPR) of $500m, an increase in denials from 10% to 12% could squeeze operational margins from 3% to 2.6%, resulting in a drop in net income from $15m to $13m. In an organization with a GPR of $2000m, an increase in denials from 18% to 20% could wipe out a 0.35% margin completely, causing net income to fall from $7m to 0. Some providers are choosing to stick with their existing processes; changing course seems too risky within thin margins. But as Eric Eckhart points out, “the just-work-harder approach doesn't work anymore.” Providers need a more efficient way to sustain operating margins. How AI Advantage helps reduce denial volume and improve net collections AI technology is emerging as a better alternative to the status quo. By using automation and AI, providers can gain insights into their claims and denial data, resulting in improved financial performance, greater efficiency and improve the future of healthcare claims management. AI Advantage™ – Predictive Denials uses AI to identify claims with a high likelihood of denial based on an organization's historical payment data. This allows staff to intervene prior to claim submission. It identifies undocumented payer adjudication rules that result in new denials. It works within Experian Health's ClaimSource® solution to proactively flag at-risk claims, allowing teams to review them within their existing claims workflow. Key takeaways from 2 real-world examples of AI in healthcare claims management Eckhart and Earley share how they are approaching denial prevention in today's fast-changing claims environment. Below are the key takeaways from their conversation about how AI is helping to optimize reimbursement and support their teams: Providers need to move beyond the “just work harder” approach to claims management Eckhart says that staffing challenges were a major driver of his organization's early adoption of AI Advantage, as it became harder to manage the increasing rate of denials with existing resources: “I think we've all tried the “let's work very hard approach” and worked overtime for months on end, but that's just not a long-term solution. We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with [AI Advantage] and the results we're seeing now.” Skylar Earley agrees, saying that despite their efforts, the rate of denials stayed the same. “It's so important for us to reduce denials because costs are increasing, reimbursements are decreasing, payments are shrinking. In our smaller community, there are only so many ways to grow revenue. We've got to maximize reimbursement, however we can.” Discover how Schneck Medical Center used AI to prevent claim denials.   Seamless integration with ClaimSource® was key to staff adoption While senior leadership teams may have been on board with testing the new technology, staff members were more hesitant about the potential pitfalls of introducing a new tool. Eckhart says, “Experian were already processing our claims through Claim Scrubber, so the workflow was essentially the same. I got some pushback when I said it was AI. I think the biggest fear for my billers was that they were going to get 5000 alerts that they would have to override and ignore. But we phased it in slowly and that was a good approach.” Earley agrees: “This is probably one of the most seamless products I've seen: it's entirely in ClaimSource®. If you didn't know about it, you wouldn't know it was there. The people using the product don't toggle back and forth between screens, they don't run reports to view alerts. The product shows them what claims they need to look at.” The predictive model gives staff their time back – so savings snowball For both organizations, a big win from AI Advantage was being able to reduce denials so staff could focus on other tasks. Making better use of staff time is increasingly urgent as the growth in denied claims outpaces recruitment. Eckhart says that over the last six months, his team have saved 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.” Reducing denials with accurate predictions Eckhart and Earley report that the success of the tool comes down to the accuracy of predictions, and the fact that it uses their own data. This applies to claims submitted to commercial and government payers, including prior authorizations. For example, Schneck Medical Center is seeing an ongoing reduction in AR days, while the number of authorized outpatient visits has increased by around 2.5% since implementing the technology. In addition to improving claims management processes, AI Advantage also helps root out persistent payer errors. Eckhart says that while denials teams tend to focus on high value claims, smaller payers can sometimes make erroneous denials that add up over time. The tool brings this to light so providers can raise it with the payer and fix it going forward. The future of healthcare claims management is here Ultimately, every prevented denial means more dollars coming back to the provider, increasing their capacity to deliver high quality services. Revenue growth makes it possible to recruit more staff, reduce outsourcing, increase capital purchases, introduce new service lines, and even explore merger and acquisition strategies. Payers are already making strides in their use of AI technology and automation, but with AI Advantage, providers can process accurate claims and reduce denials at a scale and pace to match. Find out more about how AI Advantage™ is changing the future of healthcare claims management and watch the webinar to hear the full conversation on 'The Future of Claims Management. Today.'  

With the ability to be applied across many different areas – from disease prediction to claims management and administrative tasks – data and analytics in healthcare is booming. In fact, according to a Grand View Research report, the global market for data analytics was valued in 2022 at $35 billion and is expected to increase at a compound annual growth rate of 21.4% until 2027. So, why the rapid growth? How can healthcare data analytics be used across the healthcare revenue cycle? The role of data and analytics in healthcare Historically, there has been a large amount of healthcare data being generated, but the industry has struggled to properly leverage this data into useful insights that improve patient outcomes, operations, or revenue. Today, with increasingly advanced data analytics, healthcare providers are using real-time data-driven forecasts to stay nimble and pivot quickly in rapidly changing healthcare and economic environments. And there is more data collaboration between healthcare organizations to convert analytics-ready data into business-ready information, thanks to the ability to automate low-impact data management tasks. Data-derived intelligence is also now easier to share with colleagues, third parties and the public. Types of healthcare data analytics methodologies and tools Healthcare data analytics involves several different types of methodologies and tools – all of which can be applied to various aspects of revenue cycle management. For example, descriptive analytics allows organizations to review data from the past to gain insights about previous trends or benchmarks. Predictive analytics, on the other hand, uses modeling and forecasting to help predict future results. When a strategic course of action is needed based on certain data inputs, prescriptive analytics is used. If a provider wants to take a deep dive into raw data to uncover patterns, outliers, and interconnection, they may employ discovery analytics. There are also generally three categories of technology-driven tools that can help collect and convert raw data into usable insights during the revenue cycle, including: Solutions that gather data from a wide variety of sources, such as patient case files, machine-to-machine data transfers, and patient surveys Programs designed to scrub, validate, and analyze data in response to a specific question being researched Software created to leverage the results produced by the analysis into actionable suggestions that be applied to meet specific goals Applying data analytics to maximize revenue “There are many things driving near-constant change in the healthcare revenue cycle, including shifting reimbursement, evolving value-based payment models, growing regulatory pressures, and increasing provider risk and patient responsibility,” says John Menard, VP of Product, Analytics, at Experian Health. “Healthcare organizations are also adapting to value versus volume reimbursement models, requiring revenue cycle leaders to lean into leveraging data analytics to improve not just operational efficiency, but patient financial experience and quality outcomes as well." Here's a closer look at how data analytics can help with revenue cycle management: Assessing patient finances From registration to collections, data analytics can play a key role at every step of the patient journey – and revenue cycle. Not only can the right data analytics tools help healthcare organizations better assess a patient's individual financial circumstances, but they can also help providers create accurate estimates and payment plan recommendations. Data-driven technology can help providers reduce surprise billing through more transparent pricing, helping patients navigate the cost of care and providing more timely patient communication. Digital solutions can help improve the patient financial journey by: Providing a self-service patient portal – With a solution like PatientSimple, patients get convenient 24/7 access to self-service account management tools. They can use the online portal to log into their healthcare account to securely process payments, request or review payment estimates, and schedule appointments. The portal also provides patient access to pricing information, plus the ability to apply for financial assistance or set up payment plans. With easy-to-use patient online tools, patients are more likely to meet their self-pay responsibilities and providers get paid more quickly as a result. Offering payment solutions – To collect payments with confidence, healthcare providers can utilize comprehensive data collection and advanced analytics through a digital solution like Patient Financial Clearance. With this solution, providers use a patient's financial data to quickly assess a patient's propensity and likelihood to pay prior to treatment. When appropriate, providers can then offer empathetic financial counseling and connect those that potentially qualify to financial assistance programs. By applying data analytics to this payment solution, healthcare organizations can increase point-of-service collections while reducing bad debt—in real-time. Providing patients with more accurate estimates – A recent Experian Health study found that 4 in 10 patients said they spent more on healthcare than they could afford. However, when patients know the expected cost of their care up front, they feel more empowered and make better decisions. Patient Estimates lets providers create more accurate estimates, eliminate manual tasks and improve patient satisfaction. Plus, it allows providers to automate and standardize their price transparency practices, which can help healthcare organizations meet regulatory requirements, create a more positive patient experience and increase revenue at the point of service. Reduce denied claims According to Experian Health's 2022 State of Claims survey, denied claims are on the rise with 42% of providers reporting that denials increased in the past year. 47% of respondents also said improving clean claims rates was a top pain point. Digital solutions can help providers reduce denied claims and increase revenue by: Automating claims management – With a solution like ClaimSource®, providers can automate their claims management systems – helping to ensure claims are clean before they are submitted to a government or commercial payer. Using an automated solution also allows providers to streamline the claims management process from a single web application. With ClaimSource, providers can easily analyze claims, payer compliance and insurance eligibility. Plus, it allows staff to prioritize their workload and focus on high-impact accounts – resulting in claims denial rates of just 4% compared to the industry average of more than 10%+. Optimizing efficiencies through artificial intelligence – Incorporating artificial intelligence (AI) into an automated claims management solution enhances the claims process in two key moments: before claim submission and after claim denial. AI Advantage™ integrates seamlessly with ClaimSource to continuously learn and adapt to ever-changing payer rules. The solution features two AI offerings, AI Advantage – Predictive Denials and Denial Triage, which can be customized to prioritization thresholds. Verify insurance and patient information Missing patient healthcare data can be a headache for providers to hunt down but looking for active coverage is often necessary. Providers must contend with a range of factors impacting patient coverage – including forgotten coverage, inadequate coverage, patients being misclassified as self-pay and regulatory changes, particularly with Medicaid and Medicare coverage. Implementing digital solutions can help providers use data to verify and find missing patient health insurance coverage, optimize patient collections, and boost revenue by: Utilizing automated, real-time insurance verification – Verifying patient coverage prior to service using a digital solution, such as Experian Health's Insurance Eligibility Verification. This tool can help providers experience fewer payment delays and claim denials. Plus, verifying insurance with automated insurance eligibility and benefits data improves cash flow, reduces claims denials and speeds up payments, including Medicare reimbursements. Patients also feel empowered with accurate payment estimates and accelerated registration, leading to a better patient experience overall. Improving collections with better data – With Collections Optimization Manager, providers can screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Through targeted collection strategies, providers can leverage actionable insights to focus on high-value accounts. Plus, predictive algorithms and data-driven rules help providers route and distribute accounts to the right collectors and agencies, controlling overall collection costs. This solution also connects providers to live support from an experienced optimization consultant that will help develop a tailored collection strategy through data evaluation and industry knowledge. Finding unidentified coverage – In 2022, Coverage Discovery tracked down previously unknown billable coverage in 28.1% of self-pay accounts, finding more than $64.6 billion in corresponding charges. Providers can use Experian Health's Coverage Discovery solution at any point in the revenue cycle to look for previously unidentified coverage – maximizing insurance reimbursement revenue and reducing accounts sent to collections, charity, or bad debt. Coverage Discovery also automates self-pay scrubbing and proactively identifies billable Medicare, Medicaid, and private insurance options, using a mix of search, historical information, proprietary data sources and demographic validation. See how the right data and analytics can help providers better understand their patients, streamline operations, and improve revenue.

Many hospitals and health systems are rethinking their responses to the growing challenge of healthcare claims management. After all, claims are becoming increasingly more complex. Payer policy edits are changing at a scale not seen before. And the legacy of the pandemic continues to take a toll on administrative workflows. In Experian Health's State of Claims survey 2022, providers reiterated the urgent need to optimize claims management – and the mountains of wasted dollars that are the by-product of preventable denials. Could artificial intelligence (AI) and machine learning (ML) be the key? What does the future of healthcare claims and AI look like? The internet is buzzing with excitement about the AI revolution, but the adoption of AI technology in healthcare has been slow, compared to other industries. Providers may be unclear about implementing AI effectively or struggle to see a route around barriers to adoption. This includes concerns around legacy systems and data interoperability. That said, the uptake of AI in healthcare shot up by 167% between 2019 and 2021, as organizations spotted opportunities to leverage new technology to reduce denials, optimize processes and identify patterns. Now, the AI genie is out of the bottle. As the trend continues to grow, providers that fail to embrace these technological advances risk falling behind as their competitors race forward. This article looks at AI's role in the future of healthcare claims management, and specifically, how it can help providers streamline claims processing, recoup more revenue and gain a competitive edge. The growing challenge of healthcare claims management In Experian Health's State of Claims Survey 2022, providers said reducing denials was their number one priority. It's clear to see why. There have been more than 100,000 payer policy changes between March 2020 and March 2022. Staffing shortages continue to put pressure on both front-and back-office teams. Increasing patient volumes and changes to insurance coverage means more claims to process – with more complexity to boot. Looking ahead, providers need to find more efficient ways to manage and utilize increasing volumes of claims data to alleviate staffing pressure, improve productivity and future-proof against unexpected events. Failure to do so could be an expensive mistake, especially when margins are already tight and the economic landscape remains shaky. Digital claims management: from process-automation to pattern-spotting The survey suggests providers are increasingly turning to automation to improve claims management, with 78% saying they were likely to replace their current solution to achieve lower denial rates in the coming year. Upgrading claims technology, automating the tracking of payer policy edits, and automating patient portal claims reviews were the top three strategies for reducing denials. Automation can generate years of ROI by executing repetitive and error-prone administrative tasks at speed and at scale. A few examples of automation in action are tools like: ClaimSource®, which manages the entire claims cycle, creating custom work queues and automating the claims process for greater efficiency and accuracy. Claim Scrubber, which automatically reviews every line of every claim to check for errors, so claims are clean the first time, prior to submission.  Denials Workflow Manager uses automation to help providers eliminate manual processes, prevent errors and increase reimbursement. AI takes this a step further, by analyzing vast amounts of information to find patterns and make predictions that support better, faster decision-making. Clarissa Riggins, Chief Product Officer at Experian Health explains why providers should embrace AI in claims and denials management: "Claims submissions and managing claims after denial are highly manual processes – and they are both extremely error-prone. AI/ML can learn from the data patterns in your claims to provide insights on where your claims are being denied most frequently. These solutions can also provide decision support to staff to help them to prioritize the work within their current claims processes, to avoid unnecessary denials in the first place and then to optimize their work to ensure a cleaner claim rate." While many providers see the potential of AI to streamline claims operations, prevent denials and accelerate reimbursement, others are hesitant to invest or are stumped by logistical barriers. Legacy technology, data compatibility issues and staff skills gaps can all put the brakes on AI implementation. But the AI train is showing no signs of slowing, and providers that fail to jump aboard could get left behind. With the right tools and an experienced vendor, implementation can be simplified. AI Advantage™ – the engine for predictive denials and denials triage Experian Health's new AI-powered denials management solution uses a two-pronged approach to predict, prevent and prioritize denials. First, AI Advantage – Predictive Denials identifies claims that may be at risk of being denied, based on analysis of historical payment data and payer decisions. This gives staff time to intervene and make any necessary amendments before the claim is submitted. The second element, AI Advantage – Denial Triage, applies an algorithm to segment denials based on the likelihood of reimbursement. This means staff can focus on high-impact resubmissions, rather than simply prioritizing high-value claims that may or may not be paid. Rob Strucker, Product SVP at Experian Health, explains that AI Advantage™ is continuously learning in real-time, so that predictions are increasingly accurate: “We look at the provider's own information for this type of service for this payer, and how those claims have been adjudicated. From that, we can score each claim in terms of its probability of being denied or claimed, and then based on that probability score, trigger an appropriate alert.” How Schneck Medical Center optimized healthcare claims management with AI Advantage™ AI Advantage™ proved to be the solution Schneck Medical Center was looking for when they set out to reduce denials. Within six months, Experian Health's AI-powered solution enabled Schneck to reduce denials by an average of 4.6% each month. Staff reported that the probability thresholds calculated by AI Advantage™ were highly accurate, facilitating a more efficient approach to reworking claims. Processing time was cut from 12 to 15 minutes to less than 5 minutes per claim. Clarissa Riggins says that AI Advantage gives staff confidence that they're spending their time on the right tasks: "When you have an algorithm that can evaluate the probability that a denial will be overturned, you can make sure that staff are working on the claims with the most potential for yield. Taken together, these solutions can help ensure that hospitals and health systems are getting paid for the good work they do in delivering care." Thanks to the tool's predictive capabilities, staff now have the insights (uncovered from within their own data) to prevent denials before claims are submitted, and to speed up rework should any be denied. As claim denials continue to increase in number and complexity and healthcare costs continue to grow, providers are feeling the impact on their revenue and margins. AI can ease the pressure by optimizing the healthcare claims management process. Find out more about how AI Advantage™ can help providers improve healthcare claims management and prevent costly claim denials.

Healthcare claims management is getting a much-needed infusion of technology. Artificial intelligence (AI) is the key player, utilizing vast amounts of data related to human behavior and health to forecast patterns in disease outcomes with greater precision than ever before. The same analytical power can be applied to claims data to predict and prevent denials. Using artificial intelligence for claims management is now more crucial than ever. By rooting out errors, evaluating trends and predicting payer behavior, AI helps reduce the likelihood of denied claims and maximize revenue opportunities. Staff can spend less time “treating” the effects of denied claims. But even when denials occur, AI still plays a role, quickly triaging high-value denials so staff uses their time efficiently. This two-pronged, proactive and reactive approach is captured in Experian Health's AI Advantage solution™. Using AI-powered analytics and automation, this technology helps providers predict, prevent and process denials to improve claims management and increase revenue. It's time to update claims management systems In Experian Health's State of Claims survey, nearly 3 out of 4 healthcare executives said reducing denials was their top priority. Denials are increasing in number, taking longer to process and taking a bigger bite out of provider profits. Traditional claims management strategies are no longer fit for purpose. The volume and complexity are too much for manual processes to handle, resulting in errors, time-consuming rework and lost revenue. Many providers are using automated claims management platforms to code and edit claims before they are submitted. Automation is ideal for these highly repetitive processes. Faster and more efficient claims processing increases clean claim rates and speeds up reimbursement. Experian Health's automated claims management solutions are designed with these outcomes in mind, with ClaimSource® and Contract Manager named among the best-performing claims management products in 2023, according to a KLAS report. Artificial intelligence builds on the benefits of automation, providing insights and recommendations to drive better decision-making. While automation frees staff from time-consuming, process-driven tasks, artificial intelligence allows them to perform remaining tasks at a higher level. For example, when it comes to processing denials, staff will often “guesstimate” each claim's potential for payment. They'll usually focus on reworking the highest-value denials first. AI removes the guesswork so staff can prioritize denials based on monetary value and likelihood of reimbursement, so time isn't wasted chasing higher payments that may never materialize. Using artificial intelligence for claims management can predict and prevent denials A successful denial reduction strategy starts upstream, to proactively prevent denials before they occur. AI Advantage ­– Predictive Denials uses AI to review claims before they're submitted and flag any that are likely to be denied, based on historical payment data and payer adjudication rules. The tool detects changes to the way payers handle denials, even if those aren't explicitly documented. If a claim exceeds the (customizable) threshold for probability of denial, Predictive Denials alerts the appropriate biller, who can then intervene and make corrections prior to claim submission. The benefits of this “early detection” approach include: Reducing the number of denials to be processed (and staff time spent processing them) Reducing AR days by flagging high-risk claims Improving patient satisfaction by avoiding lengthy appeals processes. After using AI Advantage – Predictive Denials for six months, Schneck Medical Center reduced average monthly denials by 4.6%. Reworking claims flagged with a predictive alert took 3–5 minutes, which was significantly quicker than before. By frontloading staff time to get claims right the first time, less effort was spent on denials. Implementation was straightforward, with no disruption to the existing claims workflow. Triaging denials for faster, more effective rework The second piece of the AI Advantage solution addresses denials that haven't been prevented. AI Advantage - Denial Triage uses advanced algorithms to identify and segment denials so staff can focus on the most profitable resubmissions. Denials are automatically triaged into five customizable categories based on likelihood of approval. Staff can rework the claims in their work queue without wondering if they're putting their effort in the right place. By automating decisions about which claims to prioritize for rework in real time, Denials Triage eliminates time spent on low-value denials and increases revenue by prioritizing high-value claims. As with Predictive Denials, this reduces the administrative burden on staff, expedites AR days, and increases patient satisfaction by reducing time to decision. Extending the automation advantage To maximize reimbursements, providers need to look at opportunities to leverage automation and artificial intelligence across the entire claims ecosystem. AI Advantage integrates with existing systems and workflows to leverage the impact of tools such as ClaimSource®. ClaimSource manages the whole claims cycle from a single online application. AI Advantage uses real-time insights generated by ClaimSource to detect patterns and predict future payer behavior. Other ways to use automation to improve claims management include: Automated claim scrubbing - Claim Scrubber uses machine learning to assess which claims have been denied in the past and why. Claims can be tagged for extra checks before being prepared for processing, to ensure likely errors have been avoided. This helps eliminate undercharges, reduce errors and minimize rework. Enhanced claim status monitoring – This helps providers keep track of existing claims. Automated status requests based on each payer's adjudication timeframe reduce manual follow-up work and allow staff to respond promptly to issues. Gathering insights into potential problems before the electronic remittance advice and explanation of benefits are processed creates time to make corrections. Using a denials workflow manager - This system automates and optimizes the denial management portion of the claims cycle, so staff can improve productivity and speed up reimbursement. With a single vendor, these tools and systems are designed to work cohesively, so there are no issues with interoperability. Data is reliable, accessible and integrated, so automation can pull from the most up-to-date and complete sources. This data can feed into proprietary machine-learning algorithms to predict and shape future performance. Experian Health's suite of automated claims management software solutions also comes with support from experienced claims-specific experts, who can help staff optimize their set-up and workflows. With the rise of AI, the healthcare industry is turning towards a more proactive approach to claim denials. Leveraging artificial intelligence for claims management can improve the overall efficiency and accuracy of healthcare claims processing, leading to fewer denials and a more seamless patient experience. Instead of waiting for denials to occur before taking remedial action, providers can use AI and automation to proactively detect errors and diagnose weaknesses in the claims process for a healthier revenue cycle. Discover how AI Advantage can help healthcare organizations predict and prevent claim denials.

“The challenge we sought to overcome by leveraging AI Advantage at our organization was just gaining more insight into how denials originate and what actions we can take to prevent those from happening.” — Skylar Earley, Director of Patient Financial Services, Schneck Medical Center Challenge Starting as a 17-bed hospital more than 100 years ago, Schneck Medical Center now serves four counties in Indiana, with a staff of more than 1,000 employees, 125 volunteers and nearly 200 physicians. The organization’s vision is to deliver excellence, lead transformation and advance health, underpinned by a patient-first philosophy. For the Patient Financial Services team at Schneck Medical Center, reworking denied healthcare claims was often time-consuming and inefficient. Billers tended to prioritize high-value claims, without knowing the probability of reimbursement. They sought a denial management solution that would reduce the risk of denied claims and minimize their impact on the revenue cycle. Solution Schneck worked with Experian Health to test two new denial management solutions that use artificial intelligence (AI) to reduce the likelihood of denials and prioritize rework to maximize reimbursement. The first, AI Advantage™ – Predictive Denials, uses AI to predict claims that have a high chance of being denied, so they can be corrected before the claim is sent to the payer. If a claim review exceeds the suggested threshold for denial probability, an alert is triggered, and the flagged claim is automatically routed to the appropriate biller. The biller investigates the alert to understand what changes are needed. This might include checking insurance eligibility, reviewing coding errors or reviewing authorization status. Once the alert is resolved, the claim can be automatically resubmitted. The second solution, AI Advantage™ – Denial Triage, prioritizes denials based on the potential for reimbursement so staff can focus recovery efforts on the right claims. The triage process starts with identifying between 2 and 10 denial segmentation categories based on likelihood of reimbursement. Schneck chose to identify 5 categories to start. Individual remits are evaluated and automatically assigned to the appropriate category, so they can be routed to the correct specialist. The tools use historical claims data and a continuously learning AI model to detect patterns in payer decisions. Staff can customize denial probability thresholds and segmentation criteria to ensure claims are routed to the correct specialist. The solutions integrate seamlessly with Schneck’s existing claims management system, ClaimSource®, and other health information workflows. Outcome After just six months, AI Advantage helped Schneck reduce denials by an average of 4.6% each month. Corrections that would previously have taken 12 to 15 minutes to rework can now be processed in under 5 minutes. Staff report that the thresholds determined by AI Advantage – Predictive Denials are highly accurate, leading to better decision-making when reworking claims prior to submission. And with AI Advantage – Denials Triage, staff feel confident that they’re focusing their attention on the right segments, rather than wasting time on high-value claims that are unlikely to be reimbursed. Skylar Earley says, “Before, we had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages.” Learn more about how AI Advantage generates insights to help healthcare organizations reduce time spent working denials and maximize reimbursement.

Experian Health is very pleased to announce that it ranked #1 in Best in KLAS, Software and Professional Services, for two segments:  #1 in Claims Management and Clearinghouse, for our ClaimSource® claims management system  #1 in Revenue Cycle, Contract Management, for our Contract Manager and Contract Analysis product.   According to KLAS CEO Adam Gale, “The 2023 Best in KLAS report highlights the top-performing healthcare IT solutions as determined by extensive evaluations and conversations with thousands of healthcare providers. These distinguished winners have demonstrated exceptional dedication to improving and innovating the industry, and their efforts are recognized through their inclusion in this report. Congratulations to all the winning vendors for setting the bar for excellence in healthcare IT! KLAS continues to be committed to creating transparency and helping providers make informed decisions through our accurate, honest, and impartial reporting.”  Experian Health’s 2022 State of Claims survey reveals that 47% of providers said that improving clean claims rates was one of their top pain points, with 42% reporting that denials have increased in the past year. Read how Hattiesburg Clinic in Mississippi, which uses both Contract Manager and Analysis and ClaimSource, leverages ClaimSource to automate claims management and reduce denials. Learn more about how ClaimSource and Contract Manager and Contract Analysis can help your healthcare organization. 

Hattiesburg Clinic is Mississippi’s largest multispecialty clinic with over 450 physicians serving 19 counties. Claims management, patient collections and payer contract management are handled by the clinic’s Financial Services Department, which includes around 70 staff members. Challenge Hattiesburg Clinic in Mississippi sought to improve financial performance in the wake of the COVID-19 pandemic by focusing on reducing claim denials. The Financial Services Department had been hit by staffing shortages, which affected financial results. A more efficient digital claims management solution would attract and retain a high-performing virtual team, while supporting the shift away from existing paper-based systems. To submit more clean claims the first time, the Department set specific goals to: meet or exceed Epic benchmarks for primary denials maintain accounts receivable (AR) days at 42 or less process secondary and tertiary claims without waiting for the primary electronic remittance advice (ERA) to be posted. Solution Already impressed with Experian Health’s Contract Manager and Eligibility solutions, the Department chose another Experian product, ClaimSource®, to help reduce denials. Loretta McLaughlin, Assistant Director of Financial Services, said she was confident ClaimSource was a good candidate for the clinic’s claims platform: “ClaimSource seemed like the right fit for the department’s goals. The platform’s ability to customize edits, along with the level of customer support available, really set the solution apart from the alternatives.” ClaimSource uses scalable automation to prioritize claims, payments and denials. This allows staff to use their time as efficiently as possible, by working on the highest-impact accounts first. Using customizable edits and extensive national and local payer edits, it checks each claim for inconsistencies before the claim is submitted. ERA data is automatically integrated into Epic so that staff can check a claim’s status quickly and easily. With real-time reporting, staff gets insights from across the entire claim lifecycle to improve performance. Outcome The ability to integrate customizable edits was a big advantage for the clinic. They now have over 90 custom edits that help eliminate time-consuming errors, reduce denials, and allow staff to focus on the right accounts. As a result, Hattiesburg Clinic has achieved a 6.1% primary denial rate, which exceeds the Epic Financial Pulse benchmark. Despite staffing shortages, they’ve been able to accelerate receivables. They’re also seeing accelerated cash flow, now they can pursue claims from secondary and tertiary payers without awaiting the outcome of primary claims adjudication. ClaimSource is also creating a better staff experience: the tool eliminates the need for claims to be printed, so staff can work from any location. Now, over 50% of the team work from home. Thanks to automated workflows, output has been consistent despite a reduced workforce. Being able to submit clean claims the first time has a positive impact on AR days as well as staff workload. Loretta McLaughlin says: “Through ClaimSource’s automation and level of quality work, we have had to do less manual intervention.” To build on this success, the team intends to explore further opportunities to use automation to improve productivity. Options include automatically generating patient estimates, automating bad debt and refund workflows, and allowing patients to verify insurance eligibility through their patient portals. Find out more about how ClaimSource helps hospitals, health systems and physician groups reduce denials, protect profits and increase productivity through automated and scalable claims management.

With 2023 just around the corner, healthcare executives are teasing out their strategic priorities for the next 12 months. Where should they be focusing their attention? Here are the top 3 healthcare predictions to watch in 2023 and the actions needed to help providers prepare. Prediction 1: AI and automation will continue to gain traction “The time is now for providers to get ready, prepare and implement these technologies.” - ­Jason Considine, Chief Commercial Officer at Experian Health Automation came to the forefront during the pandemic, enabling essential access to care and filling in gaps created by staffing shortages. By now, the use of remote and digital tools is pretty well-established. Automation is the norm, but there’s room to leverage these solutions for an even greater ROI. As Jason Considine says, investing in technology that makes it easier for providers to get paid will be a particularly effective use of digital tools. One such example is in the digitalization of healthcare claims. Healthcare claims management processes have typically relied on manual systems. These can be slow and error-prone, creating avoidable extra work for staff and friction for patients. In the State of Claims 2022, 78% of executives said their organization would be likely to replace their existing claims management solution if convinced something else can deliver better ROI. Eliminating inefficiencies and optimizing reimbursement would certainly check that box. Tools like Denials Workflow Manager, Enhanced Claim Status and ClaimSource® use automation and detailed analytics to improve claims management performance. More claims can be processed more accurately, resulting in fewer denials and faster reimbursement. With denials increasing by 10–15%, claims automation is likely to be a top priority for many providers in 2023. Prediction 2: Patients will increasingly choose providers that offer a user-friendly financial experience  “The immediate path to better billing and payment processes may escalate pressures on providers right now, but it will yield better financial outcomes in the future for patients.” - Victoria Dames, Vice President of Product Management at Experian Health The economic downturn has put pressure on providers and patients, which we can expect to last into 2023. Patients are concerned about healthcare costs, but they’ve also come to expect a more transparent and compassionate financial experience. Experian Health's top healthcare predictions finds that reliable pricing estimates, support to find the right payment plan, and convenient and flexible payment options will be table stakes in 2023. For providers, implementing digital payment options to meet these needs may be challenging, but it’s an investment that will yield positive long-term results. More than 6 in 10 patients who have received an unexpected bill or inaccurate estimate would switch healthcare providers for a better experience in future, placing transparent medical billing at the core of attraction and retention strategies. The medical billing software outsourcing market is already experiencing historic growth as providers respond to patient demand for a digital financial experience: the market’s value is expected to grow over the next decade, from $11.1 billion in 2021 to $55.6 billion in 2032. Experian Health leads the way when it comes to creating a patient-friendly billing and payment experience, with solutions such as Patient Financial Advisor and Patient Estimates. Giving patients greater control over their financial journey with upfront estimates and tailored payment plans makes it easier for them to prepare for payments. Prediction 3: Providers that fail to create a welcoming digital front door could be closing off revenue opportunities  “Deliver convenience. People are consumers before they are patients.” - Tom Cox, President at Experian Health Automation offers opportunities for optimization throughout the revenue cycle, but one of the most crucial points is in patient access. Making patient access easier is on the list of top healthcare predictions, and for good reason - a frictionless first impression can have a powerful lasting effect. What should this look like? Cox advises that providers should “anticipate the needs of digital-first customers.” Patients expect the same personalized service they are accustomed to in other sectors, with convenience, choice and control at the center. Administrative “relics” such as the traditional waiting room clipboards and repetitive forms must be minimized where possible. A report from Experian Health and PYMNTS found that a third of patients chose to fill out registration forms for their most recent healthcare visit using digital methods. 61% of patients even said they’d consider changing healthcare providers to one that offers a patient portal. Online scheduling software and self-service registration makes it easy for patients to complete these tasks in advance. Providers can then round out a user-friendly patient experience with Patient Payment Solutions. This gives patients a choice of payment methods, leading to faster payments. Providers have realized that many patient access functions can be achieved more efficiently and cost-effectively using self-service and remote digital tools. By streamlining intake operations, organizations can make better use of staff time, reduce errors and increase productivity, while improving the patient experience simultaneously. As revenue cycle technology continues to develop in 2023 and beyond, providers need to ensure they are capitalizing on the latest software to improve their bottom line, deliver on patients’ service expectations, and keep pace with healthcare predictions. Learn more about Experian Health's revenue cycle management solutions and contact us to find out how these solutions can help healthcare organizations open their digital front door and prepare for 2023.