The future of healthcare claims and AI

Published: August 9, 2023 by Experian Health

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.”

Listen in as Rob Stucker, Product SVP at Experian Health, discusses how artificial intelligence can help with claims management and reduce denials:

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.

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