All posts by Kelly Nguyen

Health payers created the prior authorization system as a cost and quality control strategy, ensuring patients receive only the most necessary, evidence-based, cost-effective and quality care. Nevertheless, real-life implementation has shown that prior authorizations often backfire on their original intents, increasing overall care costs beyond what is necessary. It also delays patient care, contributes to physician burnout and hinders operational efficiency.  Additionally, dealing with the administrative workload associated with prior authorizations can be overwhelming, time-consuming and exhausting for providers and billing teams. The sheer volume of paperwork required to navigate the traditional prior authorization system can be exhausting, particularly given the current climate of staff shortages and constantly changing payer policies.   Read on to learn why prior authorizations are crucial to reimbursements and how healthcare organizations can streamline the process using electronic prior authorizations.  What are prior authorizations?   Prior authorizations, also known as preauthorizations, is a process that involves healthcare providers obtaining approval from a health plan for a service or prescription to be delivered to a patient. This approval ensures that the plan reimburses the cost of the service or prescription.   Prior authorizations involve a series of steps. First, healthcare providers confirm the patients' qualifications for the proposed treatment. Next, they determine whether prior authorization is required. If an authorization is necessary, providers must submit information detailing the patient's medical history and other administrative information. They also have to submit supporting documents to justify the necessity and appropriateness of the proposed treatment. If the submission meets the prior authorization criteria, the plan approves the request and reimburses the cost of care.  Payers develop prior authorization criteria drawing from medical guidelines, cost considerations, utilization data and other relevant information. However, according to an American Medical Association (AMA) survey, more than one in three providers claim that these rules are rarely or never evidence-based.  Why are prior authorizations required?  Payers created prior authorizations to ensure that the specific service delivered to the patient is medically necessary, appropriate and in line with evidence-based guidelines. It is a cost-and-quality control mechanism. It is set in place so patients only receive the best and most cost-effective care option, optimizing quality while controlling costs.   Prior authorizations have been suggested to help manage the cost of care and reduce healthcare spending. Payers employ prior authorizations to prevent the arbitrary prescription of expensive treatments and medications to patients without appropriate justification. For instance, a healthcare provider might prescribe a costly brand-name medication for which a generic and more cost-effective alternative exists.  The prior authorization requirements regulations also ensure that healthcare providers administer evidence-based care and prescribe FDA-approved medications. In cases of off-label use, the requirements help encourage providers only to prescribe treatments supported by high-quality scientific literature. These medications must also meet indications endorsed by recognized sources such as the American Hospital Formulary Service Drug Information (AHFS-DI).  Challenges with traditional prior authorization methods  For many providers, dealing with prior authorization is an endless journey of starting, completing and revising paperwork. This process presents administrative challenges, leading to a significant waste of time and resources. An AMA survey found that 86% of physicians have reported that prior authorization increased healthcare resource usage.   Healthcare providers frequently allocate a large portion of their daily schedules to addressing prior authorizations. This practice takes staff time and effort that could otherwise be dedicated to providing high-quality patient care. According to an AMA prior authorization survey, healthcare providers spend about 12 hours working on 43 prior authorizations weekly. Not to mention that over one in four providers report that these prior authorization requests often or always end up being denied.   These experiences with traditional prior authorization methods have severe consequences for healthcare providers. They lead to increased physician workload, burnout, and lost time and productivity.  For patients, the time required to process manual paperwork can be a frustrating roadblock to accessing timely care. A convoluted prior authorization process also adds extra hurdles to working with different healthcare specialists for patients with multiple chronic conditions. Consequently, processing prior authorizations through traditional methods could lead to delays in care and even treatment abandonment.   The impact on patient outcomes is also quite significant. According to the AMA, more than nine out of 10 doctors report negative effects due to prior authorizations.   Additionally, payer policies are constantly changing, compounding this issue. It's hard for providers to stay up-to-date and ensure submissions are accurate. These new changes are often unannounced, making it more likely for healthcare providers to make prior authorization requests based on outdated rules. As a result, many of these submissions are instantly rejected.   Challenges with traditional prior methods point to one fact: the need for a more efficient prior authorization system is evident and urgent.  Why healthcare providers should use electronic prior authorizations  Electronic prior authorization entails systems or solutions that streamline the process of obtaining approval for proposed medical procedures, services and medications to be delivered. These systems enable healthcare providers to initiate authorization requests electronically, eliminating the need for manual paperwork processing. They are designed to improve operational efficiency, reduce healthcare providers' administrative burden and ensure patients receive care as early as prescribed.   Alicia Pickett, Senior Product Manager at Experian Health, says, "As healthcare providers face increasing administrative demands, automating prior authorizations is no longer just an efficiency measure—it's a necessity. By streamlining this process, we enable providers to focus on what matters most: delivering timely, high-quality care to their patients."  Overall, electronic prior authorizations connect payers' objective of only remunerating high-quality, appropriate and cost-effective care and providers' aspiration to bypass excessive procedural prerequisites for reimbursement. They also help ensure patients enjoy seamless and timely healthcare encounters that culminate in favorable clinical outcomes.  The benefits of electronic prior authorization solutions  The traditional prior authorization workflow can be tedious, time-consuming and error-prone. Enter electronic prior authorizations. Its unique capabilities offer many advantages for hospitals, healthcare providers and patients.  Neeraj Joshi, Product Director at Experian Health, says, "The true value of electronic prior authorizations lies in its ability to remove barriers to care. By reducing approval times and minimizing paperwork, patients receive faster access to the treatments they need, ultimately leading to better outcomes and fewer delays in critical care."   Here are some benefits of using electronic solutions to address prior authorization hurdles.  Reduced administrative burden  Prior authorization can be lengthy and frustrating when healthcare providers have to gather, review and complete hundreds of pieces of paperwork weekly. Electronic prior authorizations accurately and efficiently take care of these burdens in a way that human efforts cannot replicate.   Improved operational efficiency  Electronic solutions for prior authorizations are a partner tool that helps hospital management allocate resources appropriately. They can also help reduce staff workload and workflow, even amidst staff shortages. By freeing healthcare providers and staff from the time-consuming task of handling prior authorization paperwork, they can focus more on enhancing patient experience, care and satisfaction. As a result, hospitals have a more productive, less stressed and efficient workforce.  Reduced claim denials  Errors in the prior authorization process are a leading cause of claim denials, particularly when hospitals use traditional methods. Electronic authorizations help reduce the risk of claim denials by ensuring accuracy and completeness at every step of the submission process.   Improved patient experience and outcomes  Traditional prior authorization methods lead to costly care delays and frustrating patient encounters with the healthcare system. On the other hand, electronic accelerates time to care delivery, reducing the likelihood of patients experiencing adverse effects.  Increased hospital financial resources  By automating the prior authorization stage, healthcare organizations can speed up the entire claims and revenue management process. This accelerated system also helps reduce claim denial rates and boosts reimbursement rates. As a result, cash flow improves, ultimately strengthening their financial standing.  Key features of prior authorization software  Experian Health's prior authorization software, Authorizations, is an integrated online service that automates the inquiry and facilitates the submission processes for prior authorizations. The system automatically fills in payer information, and users are only infrequently prompted to make inputs.  Key features of the prior authorization software include:  Knowledgebase: Authorizations can access real-time and up-to-date prior authorization requirements and criteria in the National Payer Rulesets.   Submissions support: The software guides users to the appropriate website and presents patient data in an efficient format so that users can create clean submissions.  Enhanced workflow: It works with dynamic work queues, which provide an instant view of the prior authorization status and guide users through any pending tasks.  Postback: Users can send information about authorization status to the health information system (HIS) and practice management systems (PMS).  Image storage: Images of payer responses can be received and stored securely in the software's integrated document imaging system.  Reconciliation: The software offers insights into and helps resolve authorization variances, allowing staff to take proactive steps to prevent denials and appeals.   Electronic prior authorization solutions are a valuable time- and resource-saving investment for stakeholders in hospital revenue management. According to the Council for Affordable Quality Healthcare (CAQH), the healthcare industry could save around $494 million annually by using them. In addition, providers can save 11 minutes per prior authorization transaction with electronic solutions.  Additionally, electronic prior authorization software creates a win-win situation for healthcare providers and payers: Payers only release payments when necessary and hospitals get steady, adequate cash flow to meet the operational expenses of delivering quality care.   Find out how Experian Health's electronic prior authorization software, Authorizations, helps healthcare organizations achieve faster reimbursement rates.  Learn more Contact us

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

What happens when payers don't comply with contract terms? What if a provider overlooks the fine print? Contracts between healthcare providers and payers are supposed to make each party's responsibilities crystal clear. The reality is often murky. Providers face expensive consequences if they fail to adhere to payer policies – yet they often struggle to hold payers to the same level of accountability when it comes to being paid on time and in full. That's why good contract management matters. Ensuring both parties are aligned from the start protects providers from unmet expectations and revenue loss. This article looks at how contract management software for healthcare helps streamline this process, reduce misunderstandings and secure a more predictable revenue cycle. Understanding contract management in healthcare Contract management in healthcare includes all the processes involved in negotiating, executing and monitoring agreements between payers and providers. As healthcare services (and how they're financed) become more complex, it's increasingly important that these contracts are airtight. Providers need assurance of proper reimbursement, while payers want to control costs. Robust contract management helps avoid disputes so both sides can meet their financial and operational goals and maintain an effective working relationship. As Timothy Daye, Director of Managed Care Contracting at Duke Health Integrated Practice, puts it, “It's about getting paid correctly per your contracts, so you don't leave money on the table.” Challenges in healthcare contract management The challenges that could leave money on the table fall into four main areas: Complex negotiations: Providers handle thousands of contracts with multiple plans and provisions, all subject to changing regulations. Managing these negotiations can be time-consuming and overwhelming. Limited data analysis and visibility: To negotiate better contracts, providers need to factor in performance data for existing contracts and current figures for patient mix and volume. Evaluating contract terms is extremely difficult without access to the right data and models. Conflicts over claim denials: Underpayments and denials are the biggest challenges for providers, with payers reportedly denying 15% of all claims initially. Disputes over claims, payments and contract interpretations strain relationships and disrupt revenue cycle performance. Reliance on inefficient and manual processes: Poorly defined processes and miscommunications contribute to a lack of clarity when it comes to contract governance. Paper-based systems that lead to errors, delays and millions of wasted dollars don't fulfill the brief. Key features of contract management software To tackle these challenges, healthcare providers are increasingly turning to contract management software. Experian Health's Contract Manager solution improves efficiency and accelerates reimbursement by automatically checking claims before submission and validating expected reimbursement against allowed amounts. Here's how it works: A team of contract analysts assesses the organization’s contract terms, fee schedules and payment policies to clarify what’s required and when. Accurate rates and authorization rules are populated automatically to minimize pricing errors and reduce manual effort. Contract mapping and claim valuation logic reduces the risk of audits and penalties, while automated alerts help providers ensure their contracts comply with current healthcare regulations. Configurable online dashboards give staff immediate access to reimbursement reports, so they can compare expected and allowable amounts and monitor performance. Unlike manual systems, contract management software can be easily scaled for organizations of any size. Because it integrates seamlessly with existing hospital information and practice management systems, Contract Manager can audit claims for a single medical practice or a large health system with one solution. Watch the webinar: Hear how OrthoTennessee used Contract Manager to validate reimbursements, pursue bulk appeals and recover underpayments at scale. Benefits of using contract management software Simplifying contract management with software results in three main benefits for providers: 1. Increase revenue by validating reimbursements and reducing underpayments Automated oversight of payer contracts makes it easier to find discrepancies between the amounts billed and the rates agreed in payer contracts, resulting in increased revenue. This software helps providers avoid missing out on reimbursements because of buried contract clauses and supports contract-based appeals to recover underpayments. 2. Negotiate better terms (and relationships) with payers Contract management software allows providers to evaluate contract results and use that information to assess proposed terms for new contracts. This puts providers on a stronger footing in negotiations and allows them to agree to more favorable terms. More effective communications and quicker dispute resolutions also improve provider-payer relationships. 3. Streamline workflows for speed and scale Finally, automated workflows combine more accurate data to process claims faster, leading to a more predictable revenue cycle. They also lower administrative costs and allow staff more time to prioritize other patient-facing and revenue-building activities. For these reasons, Experian Health's Contract Manager product was ranked “Best in KLAS” and top-client rated in Black Book™ solutions in 2024. Secure financial stability with contract management software for healthcare Contract management may not be the most visible revenue cycle activity, but even a small change in terms can make or break financial goals. As providers work to cap costs while maintaining quality, contract management software has become critical in securing fair reimbursement rates and auditing payer contract performance with confidence. Find out more about how Experian Health's contract management software for healthcare providers validates reimbursements, reduces revenue loss and strengthens relationships with payers. Learn more Contact us

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

Could a more targeted approach to patient collections help providers maximize revenue? Wooster Community Hospital (WCH) has proof that it can – to the tune of a 7.75% boost in annual collections. In a recent webinar, Kristen Shoup, Wooster's Revenue Cycle Director, and Judy Wirtz, Senior Analytics Consultant at Experian Health, shared their success in implementing a patient-centric, automated approach to collections. With Collections Optimization Manager, PatientDial and PatientText, they saw patient payments increase by $3.8 million in a single year. Watch the webinar: Learn how WCH transformed patient collections with better insights into patients' propensity to pay and automated patient outreach. Moving away from manual processes After outsourcing self-pay collections for 20 years, Wooster Community Hospital decided to bring the process in-house to give patients a better customer experience and increase cash payments. However, because they had a lean team, they needed a strategy that would make better use of staff time and ensure each patient's account was handled in the most appropriate way. Manual systems wouldn't cut it. They wanted to make better use of data and automation so staff could focus on patients who were most likely to pay and improve patient communications. Using Experian Health's Collections Optimization Manager, alongside PatientDial and PatientText proved to be the winning combination. Customizing collections with smarter segmentation The backbone of Wooster's new collections strategy is smarter segmentation. Collections Optimization Manager categorizes patients into different tiers according to their ability and likelihood to pay, using data analysis and predictive modeling. Wirtz explains how these propensity-to-pay scores, or segment scores, allow staff to tailor their collections approach and determine the right outreach for each group's needs: “Most competitors rely on historical patient payment data to calculate propensity-to-pay scores. The Experian Health segmentation score is unique, because we have access to multiple data sources, such as credit data, payment behavior, socioeconomic data and financial data. Combining these sources gives our clients a comprehensive propensity-to-pay score, which allows them to prioritize collection efforts.” Not only does the Collections Optimization Manager direct efforts to high-value patient accounts, but this tool helps the team understand patient payment patterns so they don't pursue uncollectable accounts and collect more with fewer resources. It also identifies charity eligibility, which eases pressure on patients and creates a more compassionate experience. Zero complaints with a personalized patient experience Wooster was able to use the insights generated by Collections Optimization Manager to create a more appropriate engagement strategy for each group of patients, based on their needs and preferences, and automated communications using PatientDial and PatientText. With PatientDial, Wooster automated outbound collections calls using interactive voice response (IVR). This helped patients handle payments on their own over the phone, without needing to speak to an agent. Staff can also send patients personalized text messages for an alternative but equally quick and convenient way to pay their balances. Before using these tools, patients expressed frustration at receiving collections calls at inconvenient times. Since adopting this new tailored, convenient, and unintrusive contact combination, Wooster has seen a significant improvement in patient satisfaction. The proof is in the payments Ultimately, Wooster's goal was to increase self-pay revenue. Wirtz shares that as a result of the new strategy, Wooster has seen patient payments increase by $3.8 million in just one year. The annual collection rate increased by 7.75%, with $1.47 million collected through PatientText and $485,000 through PatientDial. Encouragingly, Wooster has also seen a $600,000 drop in bad debt placements and discovered an additional $800,000 in Medicaid coverage thanks to Collections Optimization Manager. Partnering for success Shoup and Wirtz also discussed their partnership approach to determining the optimal collections strategy for Wooster. Wirtz worked closely with the team, providing dedicated support to set up and monitor workflows, discuss any pain points, and pull out benchmarking insights. Shoup says: “Judy's been a great partner, and the team at Experian Health has been great to work with. The great thing for me was being able to show the value in the changes we made. When I first decided that we needed to bring our self-pay process back in-house, and we partnered with Experian, I needed to be able to prove that what we were doing was successful. And 100%, hands down, it has been a huge success. We have collected more money, and I can monitor that and show the results using Experian's tools.” Watch the webinar on-demand to hear the full discussion, and see how Experian Health can help your healthcare organization can use segmentation and automation to create a targeted, efficient and compassionate patient collections strategy. Watch the webinar Contact us

Effective contract management for healthcare organizations is pivotal in this complex and highly regulated world. Healthcare organizations, whether large hospitals, clinics, or individual practitioners, contract with various entities, including vendors, insurance providers, and regulatory bodies. These contracts govern everything from purchasing medical supplies to services reimbursement, making healthcare contract management a critical aspect of running a successful and compliant operation. What is healthcare contract management? Healthcare contract management is the systematic process of creating, negotiating, executing, monitoring, and optimizing contracts to ensure compliance, mitigate risks, and achieve healthcare organizations' strategic objectives. It encompasses various stages, including needs assessment, drafting, execution, and post-contract management. The importance of healthcare contract management for payers and providers Healthcare contract management ensures that healthcare organizations, including payers and providers, can efficiently navigate the contracts governing operations. For providers and healthcare contract managers, it's about ensuring their organization gets paid fairly for services while adhering to complex regulations. For payers, negotiating contracts with healthcare providers helps control costs while maintaining care quality. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, states, “Better healthcare contract management directly impacts provider revenues. That's why many organizations implement healthcare contract management software. These tools help healthcare providers work smarter and get paid faster.” Challenges and opportunities in healthcare contract management The complex payer/provider landscape presents multifaceted challenges for organizations seeking to improve healthcare contract lifecycle management. The intricate web of regulatory requirements, privacy laws, provider-specific reimbursement structures, and shifting payment models adds complexity to contract management. Healthcare providers must navigate through contracts with various stakeholders, including suppliers, payers, and government agencies. Healthcare contract compliance with ever-evolving regulations is difficult in part because most providers manage these complexities manually. Providers seeking to improve healthcare contract management often turn to technology to help. OrthoTennessee, a multi-location orthopedic practice in Knoxville, Tennessee, with 164 providers, struggled with denied claims, smaller payouts, and a need for more contract management standardization. The organization used Experian Health's Contract Management tool to improve the accuracy of contract compliance. Today, this healthcare provider credits the software with helping the organization spot changes in payer rules and trends in how they pay. Experian Health's Contract Management platform drives significant efficiencies and time savings. It also provides critical data for payer negotiations. In 2022, OrthoTennessee had an 86% appeal success rate, thanks to more streamlined contract management. OrthoTennessee strongly advocates for Experian Health's Contract Management tool—and they've used it for over 16 years. Navigating the complex landscape of healthcare contract management The healthcare industry is notorious for its ever-evolving regulatory environment. Healthcare contract managers must stay up-to-date with these changes to ensure contracts remain compliant. Imagine doing this by hand when most healthcare providers deal with hundreds of different payers, each with its contracts, procedures, and paperwork. This lack of standardization slows down the claims process. With rising healthcare costs, payers and providers are under immense pressure to optimize contracts to maintain profitability while delivering quality care. As claims grow more complex and patient volumes rise, manual healthcare contract management becomes a bottleneck in getting paid. Healthcare organizations often operate in a highly competitive environment, making efficient contract management a strategic imperative. Failure to manage contracts effectively can result in lost revenue, operational inefficiencies, and strained relationships with key partners. Managing data-intensive healthcare contracts One of the most significant challenges in healthcare contract management is the data-intensive nature of these agreements. Payer/provider contracts contain vast amounts of critical information, such as billing codes and reimbursement rates. Managing this data accurately and securely is essential for compliance and successful operations. The sheer volume of contracts in healthcare organizations can be overwhelming, making it challenging to track, analyze, and report on their performance. Manual contract management processes are vulnerable to errors that can have significant financial and legal consequences. However, these challenges also present significant opportunities. The advent of technology, such as contract management software and artificial intelligence, has revolutionized the way healthcare organizations oversee contracts. These tools offer the potential to automate data extraction, analyze compliance, and streamline contract workflows, significantly enhancing efficiency and reducing the risk of errors. Frequently Asked Questions What does a healthcare contract manager do? A contract manager in healthcare is responsible for overseeing the entire contract lifecycle. Their duties include negotiating contract terms, ensuring legal compliance, monitoring performance, managing amendments and renewals, and fostering stakeholder collaboration. Contract managers play a vital role in optimizing contract efficiency and minimizing risks. What are the common types of contracts in healthcare? Provider Agreements: Contracts between healthcare providers (e.g., hospitals, clinics) and payers (e.g., insurance companies) that outline reimbursement rates and service delivery terms. Payer Contracts: Agreements between healthcare payers and providers that govern payment terms, coverage, and network participation. Pharmaceutical Agreements: Contracts between healthcare organizations and pharmaceutical companies for purchasing and distributing medications. Vendor Agreements: Contracts with vendors providing services, equipment, or supplies to healthcare organizations, ensuring quality and compliance. Better healthcare contract lifecycle management Healthcare contract lifecycle management is a comprehensive process encompassing all contract stages, from initial creation to final execution, performance monitoring, and eventual termination. This systematic approach helps organizations maximize efficiency, reduce risks, and ensure compliance with payer contract requirements. Understanding the contract lifecycle The lifecycle of an average contract has several phases. Work must be done at each step, and challenges arise even before contract signing. After signing, the healthcare contract manager must follow each payer's rules closely as they are subject to change. Pre-Contract Stage: Healthcare organizations must conduct a thorough needs assessment to define the agreement's scope before drafting a contract. This phase often involves communication with essential finance, legal, and operations stakeholders. The goal is to go into contract negotiation with a clear sense of organizational goals and where to draw the line. Payer Contract Formation: Successful contract formation involves negotiation and drafting that addresses all parties' unique needs and expectations. Key stakeholders must collaborate to ensure the contract meets legal and regulatory requirements. Standardized templates with clear, concise language minimize ambiguity and lessen legal risks. Execution of Contracts: To expedite contract execution, healthcare providers must establish approval workflows and methods for monitoring compliance after signing. This phase may include exchanging required documentation, such as insurance certificates or provider credentials. Notably, adopting e-signatures streamlines approvals, reducing common delays experienced with paper-based processes. Post-Contract Management Performance: After execution, healthcare organizations must actively and consistently monitor contract metrics against key performance indicators (KPIs). Providers must identify deviations from expected performance and address them quickly. Keep in mind healthcare contracts often require amendments and periodic renewals. Organizations must also have a standardized process for these changes and ways to manage new contract compliance workflows. How technology improves the contract lifecycle Technology plays a pivotal role in improving the entire healthcare contract lifecycle. From contract creation to execution, performance monitoring, and beyond, technology-driven solutions offer a range of benefits to enhance efficiency and improve compliance. Contract management software has revolutionized how organizations handle their contracts in the digital age. These specialized platforms offer a centralized repository for contracts, making them easily accessible and searchable. Critical features of contract management software include: Centralized Storage: Consolidates all contracts into a single, easily accessible database, eliminating the need for physical filing systems or scattered electronic documents. Automated Workflows: Reduces delays associated with manual routing and approvals. Electronic signatures further expedite contract execution. Version Control: Maintains a clear record of revisions, ensuring users consistently access the latest, up-to-date documents. Document Management: Aids collaboration, secure file storage, and document sharing. Alerts and Reminders: For contract milestones, such as changes, renewals, or termination dates, helping organizations stay on top of critical events. AI and automation in healthcare contract management AI can automatically extract essential contact data, helping organizations efficiently categorize, analyze, and report on their contract portfolio. Natural language processing and machine learning aid in contract risk assessment, compliance checks, and pinpointing critical clauses for review. Automation tools can generate contracts from standardized templates, reducing the time and effort required for contract authoring and negotiation. AI-driven contract review tools help legal and compliance teams identify deviations from standard language, flagging potential issues that need attention. Compliance checks and alerts can also be automated, ensuring that contracts meet changing regulatory requirements. Data analytics for contract oversight Data analytics for contract oversight is invaluable for overseeing contract performance and compliance. By employing data-driven insights, organizations can: Monitor KPIs to assess whether a contract is delivering the expected value. Detect anomalies, deviations from expected patterns, or changes in performance data to identify potential risks and compliance issues. Manage costs by analyzing financial data within contracts and identifying opportunities for cost reduction or resource optimization. Predict contract performance trends, helping organizations proactively address issues and make informed decisions. Ibrahim says, “There's a reason that Experian Health Contract Manager achieved Best in KLAS this year. The burden of proving a claim is underpaid or wrongly denied always rests with the provider. This software finally allows these organizations an opportunity to reduce the $157 billion annually lost on manual contract management.” Future of managing healthcare contracts The future of managing healthcare contracts will be transformational. Technology advancements will revolutionize the standard for healthcare contract lifecycle management. As technology advances, organizations that leverage these innovations stand to gain a significant competitive advantage in their revenue cycle. Some of the future innovations to expect include: Telehealth and Remote Contract Management: Telehealth will become integral to healthcare delivery. It will extend beyond traditional video consultations to include remote monitoring, diagnostics, and treatment plans and require a robust framework for contractual agreements between healthcare providers, insurers, and technology vendors. The expanding role of telehealth will necessitate innovative contract management solutions, leveraging technology and automation to ensure efficient, secure, and compliant remote contract management. Predictive Analytics and Machine Learning: These emerging technologies will reshape how healthcare providers manage contracts. Predictive analytics will enable organizations to anticipate contract performance trends, proactively identifying potential issues before they escalate. Machine learning algorithms can analyze vast amounts of contract data to uncover patterns and insights that may not be apparent through traditional methods. This predictive capability helps healthcare organizations optimize their contract management strategies, improve negotiation outcomes, and enhance overall operational efficiency. By leveraging these advanced technologies, healthcare providers can ensure compliance, reduce risks, and drive better financial and patient care outcomes. Empowering healthcare organizations for a successful future Ultimately, applying technology solutions to healthcare contract compliance and management empowers these organizations to succeed in delivering high-quality care. Healthcare is increasingly complex, and organizations must leverage technology, adopt best practices, and stay ahead of emerging trends. Experian Health's Contract Management solution allows providers to manage these complexities efficiently and improve their revenue cycle. Contact us to learn how our Healthcare Contract Management software can help your organization validate reimbursement accuracy, recover underpayments and more.

Millions of healthcare claims are denied annually, costing providers billions in lost revenue and expensive appeals. A 2024 survey shows that around 15% of all claims submitted to private payers, Medicare Advantage and Medicaid managed care plans are initially denied. Since most involve charges of $14,000 and above, the stakes are worryingly high. Frustratingly, more than half of these denials are eventually overturned, but not before providers have spent an average of $43.84 reworking each claim. With hospitals and health systems spending almost $20 billion on denial management in 2022 alone, this administrative tug-of-war with payers brings a substantial toll. While some denied claims are valid, there's no doubt that many are avoidable, as evidenced by the number that are successful on the second try. This is where effective claim denial management strategies and solutions come into play. Understanding the root cause of denials in healthcare and implementing the right systems ensures that claims are right the first time. This article looks at the importance of denial management, strategies for improvement, and why more providers are shifting from defense to offense by putting automation and artificial intelligence (AI) at the heart of their claims management processes. The importance of denial management in healthcare A traditional denial management definition in healthcare might focus on the steps needed to resolve denials after they occur. The reality is much broader. Providers need a proactive strategy that addresses why claims are denied in the first place to prevent them from occurring in the future. Claims may be denied because the insurer doesn't consider the treatment medically necessary, believes there's a cheaper alternative available or doesn't cover it because the patient's insurance doesn't cover it. Sometimes, the culprit is an erroneous billing code or typo. Providers avoid costly and time-consuming rework by ensuring that claims are accurate, compliant, and complete at the start. As denials become more common and costly, streamlining denial management is increasingly urgent. The provider-payer relationship One of the major challenges for providers is the shifting relationship with payers. According to a survey by the American Hospital Association (AHA), 78% of hospitals say interactions with commercial payers are getting worse, with 84% noting the rising costs of complying with insurer policies. Providers report spending more time on prior authorizations, yet the growing pile of denials includes pre-authorized services. The pattern of claims being denied and then granted on appeal drains financial resources, delays patient care and contributes to staff burnout. Moreover, payers have been much faster in adopting AI-based technology, allowing them to process and deny claims at an unprecedented rate. Providers that rely on traditional denial management methods are starting to fall behind. The denial management process: how it works Healthcare denial management involves four key steps: Track all claims from submission through final adjudication and identify denials as quickly as possible. Denials should be categorized by type, payer and service to identify trends and understand underlying issues that need addressing. Investigate the cause of each denied claim, such as coding errors, missing documentation or non-adherence to payer guidelines. This stage often involves collaboration among billing teams, coders and clinicians to pinpoint what went wrong. Rework the claim by gathering missing data or documents and correcting errors before resubmitting the claim to the payer for reconsideration. This will also include monitoring the outcome to see if the appeal is successful. Prevent future denials through improvement measures such as staff training, updates to billing software, and ongoing payer policy reviews. A preventive approach ensures claims are managed without a hitch and keeps revenue flowing. Strategies for effective healthcare denial management Prevent denials upstream with accurate patient access Because so many denials originate early in the revenue cycle, patient access should be the first target in any denial reduction strategy. Experian Health's Patient Access Curator solution uses AI-powered data capture technology to collect and verify patient information in seconds. A single click checks eligibility verification, coordination of benefits (COB), Medicare Beneficiary Identifiers (MBI), coverage discovery and financial information to determine the patient's propensity to pay quickly and accurately. Staff no longer need to run multiple queries and can have confidence that their claims are built on the correct data. Watch the webinar to learn how Patient Access Curator shifts denial management upstream and propagates clean data throughout the revenue cycle. Process denials more efficiently with workflow automation A second strategy is to automate the denials workflow to alleviate the administrative burden on staff and expedite the appeals process. Denial Workflow Manager automatically identifies denials, holds, suspends, zero pays and appeal status so staff can follow up quickly, without the need for manual reviews. They'll have the time and intel to rework the denials that are most likely to be overturned, resulting in maximum cash flow. When used alongside ClaimSource®, they can do all this using standardized protocols with claim and denial information on the same screen. Denial Workflow Manager provides American National Standards Institute (ANSI) reason and payer codes and descriptions so staff know precisely why a claim was denied. Reports and responses can be forwarded to Health Information and Practice Management Systems to facilitate better coordination. The tool also provides advanced analytics to identify trends and inform tactics for further improvement. This significantly reduces the overall time and cost associated with managing denials. The future of denial management in healthcare While automation has lifted healthcare denial management out of inefficient manual processes, AI takes predicting and preventing denials a step further. AI AdvantageTM enhances the denial management toolkit with two new offerings: Predictive Denials uses the provider's own claims data from within ClaimSource to identify claims that are most likely to be denied, so staff can step in to take corrective action before submitting the claim. Denial Triage analyses and segments denials that do occur so staff can focus on reworking claims with the highest potential for reimbursement. With these tools, providers can eliminate guesswork, reduce denials and minimize financial losses. But it's not just about finding more innovative ways of working: payers have already made huge strides in using AI to deny claims at speed and scale. The future of denial management in healthcare will hinge on technology, and providers will need to adapt to keep up with the fierce competition. Find out more about Experian Health's Denial Management Solutions and see why they're top-rated by clients in the 2024 Black BookTM RCM User Survey. Denial Management Solutions Contact us

Could healthcare organizations be doing more to open their digital front door? According to a 2024 study by HIMSS researchers, hospitals that embrace digital technology see stronger patient experience outcomes. This aligns with Experian Health's most recent State of Patient Access (SOPA) survey, in which patients and providers agreed that patient access had improved thanks to digital technology. Adoption of digital health technology accelerated in response to COVID-19, as healthcare organizations sought to manage demand and facilitate “contactless” access to care. Telehealth, mobile apps and patient portals gave patients more control over their health while allowing providers to deliver more personalized and efficient care. With over half of healthcare providers and nearly a third of patients acknowledging improvements in access since before the pandemic, it's clear that offering more digital options is a powerful strategy to improve patient engagement and streamline access. Progress is encouraging, but there are always opportunities to do more. What is healthcare's digital front door? Healthcare's “digital front door” includes all the digital channels through which patients access care, such as websites, patient portals, mobile registration and payment apps, telehealth platforms and online scheduling tools. The goals are to create convenient and user-friendly entry points for patients to engage with their providers, use online tools to expand access, improve patient satisfaction, and increase operational efficiency. Why a digital front door is crucial for healthcare providers When asked why they believe patient access has improved since before the pandemic, the top four reasons given by patients all relate to scheduling and registration processes: Being able to see a doctor quickly (72% agreed) Checking in and registration (61% agreed) Scheduling appointments (58% agreed) Finding appointments that work with their schedule (57% agreed). In other words, patient access improves when providers open the digital front door. Alex Harwitz, VP, Digital Front Door, at Experian Health, explains that for providers, this equates to two major benefits: 1. Improves patient engagement Harwitz says that putting access in the hands of patients gives patients more flexibility and choice about how and when they book appointments, fill out registration forms and pay for care. “There's a growing demand for easy, accessible healthcare, and opening the digital front door is how we meet it. Digital tools use automation and data analytics to create a more personalized and convenient patient experience, making it easier for patients to remember appointments, adhere to treatment plans and manage their financial obligations,” he says. “That's huge for busy households. The to-do list just got a lot shorter, so it's easier for them to engage.” 2. Streamlines patient access A second key benefit is reducing friction and bloat in patient access workflows. Harwitz says, “By expanding their online offerings, providers not only make it easier for patients to see their doctor sooner, but they also reduce demand on front office staff. Self-service options, performance reporting and data insights allow providers to allocate resources more effectively. It’s about making sure everyone gets the right support at the right time, whether that's online or in the office.” Getting the patient journey off on a strong footing also pays dividends throughout the rest of the revenue cycle: with fewer errors and faster throughput, collections and claims management improve, too. Read more: How patient access technology is transforming the healthcare revenue cycle Key components of a digital front door As more providers offer online patient access, competition for the digital front door is increasing. With 60% of patients looking for more digital and mobile options to meet with providers, schedule appointments, and manage bills and payments, these would be smart areas to prioritize for a competitive advantage. Here's what that might look like: 1. Cut paperwork and calls with self-service scheduling and mobile registration It should come as no surprise that a vast majority of patients say they do not like repetitive paperwork. Online and mobile-enabled scheduling and registration reduce form-filling and lengthy calls. For example, Patient Schedule gives patients a platform to book, cancel and reschedule appointments with ease, anytime and anywhere. Appointments are matched to patients' needs so no slots are wasted and patients see their doctor sooner. Mobile registration increases bookings further. With Registration Accelerator, patients receive a text that prompts them to scan their identity and insurance cards, so they don't need to wait in line to fill out forms. Validating their data from the start also improves billing accuracy and reduces the risk of downstream denials. 2. Make it easier to pay for care Simplifying the financial experience is a major component in opening the digital front door. Patients are worried about the cost of care and say that having accurate price estimates before treatment helps them plan for bills. With Patient Payment Estimates, providers can give patients accurate, upfront estimates of their out-of-pocket costs, while tools like Patient Financial Clearance can help direct them to appropriate payment plans. It's also important to make the actual payment process as straightforward as possible. Accepting payments 24/7 from any device allows patients to pay promptly and helps providers avoid bad debt. Checklist: 5 patient-friendly billing practices to accelerate collections 3. Communicate clearly for a great first impression At its core, opening the digital front door is about creating a welcoming first impression for patients. Patients don't want confusing instructions or radio silence when they have questions. They want proactive, helpful and clear communications. One of the benefits of digital tools is having the data and automation capabilities to send patients timely and personalized messages and reminders using their preferred channels. They can also drive targeted outreach campaigns using text messages and interactive voice responses to encourage patients to book appointments and make payments. The future of healthcare's digital front door These are just a few examples of how providers can expand their digital offerings to make it easier for patients to access care. But what will the digital welcome mat look like in the future? Advances in artificial intelligence, digital apps and wearable tech will transform the way patients interact with their providers. Hockey-stick growth in data generation will make data security and interoperability non-negotiable. It's a big ask of providers. Partnering with an expert third-party vendor will help digitally forward organizations remain responsive and adaptable. Find out more about how Experian Health helps providers open their digital front door with mobile scheduling, registration and payments.

Surprise tends to magnify human emotion. If the surprise is positive, a person's reaction to it will be intensely positive. If it's negative, it will be extremely negative. Such is the case with unexpected medical bills, and that's one reason why the No Surprises Act was passed in 2021. It aims to protect consumers from unexpected bills for out-of-network care in both emergency and non-emergency settings. Thanks to the Act, U.S. healthcare organizations must now provide transparent details of the estimated costs of their services – otherwise known as patient estimates. And, so far, it's working. One 2023 survey by Blue Cross Blue Shield and AHIP shows that "The No Surprises Act (NSA) prevented more than 10 million surprise bills in the first nine months of 2023 — continuing to protect millions of Americans from crippling medical bills each year." And as insurance deductibles and out-of-pocket expenses continue to rise, patient estimates are becoming even more critical. Experian Health's State of Patient Access Survey 2024 shows that both patients and providers would like to see improvement in the accuracy of patient estimates. Surveys show that 4 in 10 patients say they spent more on their healthcare than anticipated, and nearly one-quarter received surprise bills after treatment. Creating service transparency takes an effort, but there are also hidden benefits for providers. With medical debt skyrocketing past the $220 billion mark and the cost of care increasing, patient estimates apply much-needed rigor to healthcare billing and collections practices. Why are patient estimates important? Pricing estimates enhance the healthcare experience by making the financial responsibilities of treatment more transparent and more manageable. The benefits for patients include: Understanding potential treatment costs, allowing them to plan and avoid unexpected expenses Making informed decisions about their healthcare options by comparing the costs and benefits of different treatment plans Fostering transparency and trust between healthcare providers and patients Better coordination with insurance providers so they know what will be covered and what will be an out-of-pocket expense Reduced financial anxiety, allowing patients to focus more on their recovery and less on potential financial stress Increased cost awareness and acceptance, prompting them to comply more readily with treatment plans and not cancel appointments Providing a price quote empowers patients while creating a more efficient healthcare system of services rendered and payments received. Why are patient estimates useful prior to treatment? It's better for patients, and the healthcare system as a whole, if patients are more focused on healing and self-care than the stress and anxiety of an unexpected medical bill. If they know what's coming, patients can take control and make plans to alleviate any financial turbulence. In the case of planned care and procedures, pre-treatment cost estimates also allow patients to shop around for the best balance between service and price. In addition to helping patients make smarter treatment choices and financial decisions, patient estimates also help people understand, navigate and coordinate their insurance benefits. That also helps them avoid medical billing surprises that can later lead to collections and damage to their credit scores. How do patient estimates help providers? In today's healthcare landscape, where value and patient experience are key factors in reimbursement, transparency has become crucial in four ways: More satisfied patients: Estimates build trust and patient and provider relationships. This trust is essential for effective communication and patient satisfaction and can help reduce patient churn. Better adherence to treatment plans: Patients aware of the financial implications are more likely to stick to their treatment plans and follow through with necessary procedures and lifestyle changes. Adherence leads to better health outcomes and a more efficient treatment process. Better resource management: Knowing each patient's expected costs and required resources allows providers to allocate and schedule resources more effectively. Improved revenue flow: Pricing estimates at the front end of the medical journey establish upfront financial accountability, which can lead to providers being paid more quickly. As healthcare costs rise, improving price transparency is a win-win for both patients and providers. Patients want clear, upfront information about treatment costs, insurance coverage and payment options so they can plan ahead with confidence. When providers make this process smoother, it benefits everyone—saving time, reducing stress, and making things more efficient. Plus, it can help avoid those tough conversations when patients are caught off guard by unexpected bills. Providing the right information from the start creates a more positive experience for everyone involved. Technology can help create accurate patient estimates Experian Health's Patient Estimates tool makes price transparency and providing accurate estimates easier. This solution leverages real-time data, including insurance coverage, payer contract terms and provider pricing, so that everyone knows exactly where they stand before the service is rendered. Patients can focus on getting well while providers create the accountability they need to get paid promptly. With the right technology, patients and providers can come together in a mutually beneficial and less stressful encounter that leads to better relationships and better health. Contact us to learn how Experian Health can help your healthcare organization empower patients with clear, accurate cost estimates to enhance transparency, build trust and improve overall care satisfaction. Patient Estimates Contact us