Claims & Contract Management

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

As economists offer up their best guesses for the US economy over the coming year, healthcare leaders know one thing for sure: no matter what happens, they need solid revenue cycle management (RCM) processes to remain financially sound and deliver high-quality care. Revenue cycle management connects the financial and clinical aspects of care by ensuring that providers are properly reimbursed for their services, through accurate and efficient billing and claims management processes. Keeping the financial scales tipped in the right direction is a growing challenge: data from the American Hospital Association shows that payer delays and denials are driving up operational costs while slowing revenue. Many providers are turning to artificial intelligence (AI), automation and data analytics to eliminate inefficiencies and maximize reimbursement. Factors that affect healthcare revenue cycle management While revenue cycle math is pretty simple – money in versus money out – the reality is more complex. A tight grip on delivery costs is just one part of the equation. Most RCM efforts center around determining who owes what and collating the necessary documentation to secure prompt payment from each party. A few factors to consider include: Are there reliable processes for capturing accurate patient information? How quickly can coverage and pre-authorizations be verified? Are claims and denials managed efficiently? How easy is it for patients to understand and pay their bills? Can RCM leaders monitor and analyze staff and agency performance? Changing payer policies, patients' financial status and data management demands add to the challenge. The goal of revenue cycle management To achieve the primary aim of getting reimbursed in full and on time, organizations must reduce billing errors, submit clean claims and refine operational efficiency so staff can stay laser-focused on high-value tasks. But it's important to look beyond the spreadsheets: selecting the right tools to deliver a transparent and compassionate patient experience will boost the bottom line, too. History and evolution of RCM RCM has shifted from largely paper-based processes to sophisticated software-based systems in just a few decades. Few could have imagined how those early healthcare information systems of the 1970s would evolve as electronic health records, standardized coding frameworks and digital data processing came to the fore. Changes in regulation and reimbursement models furthered the need for advanced analytics. And now, the rise of healthcare consumerism drives demand for the industry to open its digital front door. Organizations that commit to digital transformation will be in a stronger position to navigate today's RCM challenges and meet the needs of digitally native consumers. Relationship between patient experience and RCM Experian Health's recently published State of Patient Access Survey 2024 reveals the extent to which the patient experience affects revenue. Integrating patient-centered principles into RCM processes improves patient satisfaction, makes it easier for patients to understand and pay their bills, and leads to better financial performance overall. Steps in the healthcare revenue cycle A typical revenue cycle management workflow in healthcare follows the patient’s journey. Each touchpoint in the patient's journey is an opportunity to check that patients, payers and back-off teams have the information they need to expedite payment: Scheduling – When the patient books an appointment, administrative staff verify the patient's insurance eligibility. This is a chance to make sure pricing is transparent and give the patient an estimate for the cost of care. Registration – Next, the provider captures the patients' medical history, insurance coverage and other demographics. Correct patient information on the front end reduces the errors that cause rework in the back office. Prior authorization – Front-end staff check whether the patient's insurance provider requires prior authorization for the procedure or service they need. Skipping this step can lead to costly denials and rework. Treatment and follow-up – After treatment, the back office collates billable charges and assigns a medical billing code to the claim. Accuracy is paramount, as reworking claim rejections can drain resources. Claim submission – Then, the claim must be submitted to the payer. Accurate and timely submissions prevent rejections and reimbursement delays. If a claim is denied, it must be resubmitted as quickly as possible to avoid lost revenue. Collections – Once the payer approves the claim, the patient's out-of-pocket costs are calculated and billed. Providing a range of convenient payment methods will increase the likelihood of prompt payment. Regulatory and compliance considerations At each stage in the process, staff must stay mindful of the regulatory and compliance frameworks governing revenue cycle management. These are primarily patient-centered. For example, the Health Insurance Portability and Accountability Act (HIPAA) safeguards patient privacy and sensitive health information, while the No Surprises Act seeks to make pricing more transparent. Failure to adhere brings severe reputational and financial risks, as made painfully clear by recent headlines about the cost of cyberattacks within the industry. Common challenges in healthcare RCM For most providers, avoiding the cycle of claim denials and rework is the biggest challenge. A survey of 1300 hospitals found that denials by commercial payers had increased by 20.2%, while Medicare Advantage denials had increased by 55.7% between January 2022 and July 2023. Reliance on inefficient manual processes to track and monitor claims does little to help. A 2023 CAQH report shows that switching from manual to electronic claim status inquiries could reduce the time spent on each transaction by 17 minutes, saving the medical industry more than $3.2 billion overall. Providers are also collecting increasing sums from self-pay patients. Financial pressures and uncertainty around coverage mean many patients cannot fully cover their medical expenses. Improving their financial journey with accurate upfront estimates, clear and compassionate communications, and convenient payment methods will accelerate payments. Unfortunately, there's still some way to go: the State of Patient Access Survey 2024 found that 64% of patients had not received a cost estimate before care, and of those that did, 14% reported final costs that were much higher than expected. Financial impact analysis To track the financial effects of these challenges, healthcare organizations should identify key performance indicators (KPIs) aligned to their specific priorities. Conducting real-time monitoring and analysis of patient access, collections, claims and contract management metrics can flag up opportunities to prevent revenue leakage and maximize income. Read more about how to identify the right KPIs for your revenue cycle dashboard. 4 ways to improve revenue cycle management in healthcare When it comes to implementing specific revenue cycle management solutions, the following four tactics are likely to yield the greatest return on investment: Automate AccessA healthy revenue cycle begins with quick, accurate and efficient patient access systems. Automated, data-driven workflows reduce the errors that lead to denials and rework. Online scheduling allows patients to easily book appointments, while solutions like Patient Access Curator use AI to capture all patient data at registration with a single click. Increase collectionsMaximizing patient collections while fostering a positive patient experience can be a delicate balance. Patient access staff must be the patient's advocate, while ensuring the organization collects what’s owed. Giving patients upfront estimates of their financial responsibility and offering appropriate financial plans makes it as easy as possible for them to pay. Collections Optimization Manager allows providers to focus their efforts on the right accounts, through highly predictive patient segmentation. Streamline claimsAutomating claims management is another way to use technology to accelerate reimbursement. Claims management software verifies that each claim is coded properly before being submitted. Encounters can be processed in real-time with automatic alerts to flag any issues before the claim is submitted. Experian Health's flagship AI Advantage™ solution helps predict and prevent denials by checking claims before they are submitted and calculating the probability of denial. It evaluates and segments denials that occur based on the likelihood of reimbursement following resubmission, and prioritizes the work queue so staff make the best use of time. Increase reimbursementHealthcare organizations that don't stay current on payer policy and procedure changes risk payment delays and lost revenue. Providers and payers must be on the same page to quickly resolve mismatches between expected and actual reimbursement amounts. Automated payer policy and procedure change notifications help providers strengthen relationships with payers and avoid payment delays. How healthy is your revenue cycle? Our revenue cycle management checklist helps healthcare organizations catch inefficiencies and find opportunities to boost cash flow. Case studies See how automated revenue cycle solutions helped Stanford Health optimize their patient collections strategy. See how Schneck Medical Center prevents claim denials with AI AdvantageTM Hear how UC San Diego Health used automation to improve patient billing and drive collections. Getting the most out of revenue cycle management software These case studies demonstrate that a successful revenue management strategy has three essential ingredients: data, software and training. Experian Health's “Best in KLAS” revenue cycle management solutions are built on proven technology and proprietary databases, to help staff find new opportunities to bring in revenue. Experienced consultants are on hand to guide staff and ensure workflows are set up for the best results. The future of RCM Whatever the economic outlook, technology’s defining role in the future of revenue cycle management is undisputed. Payers are already leveraging AI to their advantage, and patients have come to expect convenient digital transactions—any providers that fail to embrace AI and automation-based RCM solutions will fall behind the competition. Learn more about how Experian Health's revenue cycle management solutions generate more revenue for healthcare organizations.

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

Healthcare claim denials persist as a significant challenge, impacting the efficiency, affordability and timeliness of healthcare delivery and hospitals' financial well-being. They contribute a substantial portion of the staggering $265 billion annual in waste attributed to administrative complexities. On average, hospitals face a yearly loss of $5 million due to healthcare claim denials, amounting to 5% of their net patient revenue, according to the Journal of AHIMA. Yet it appears that the rise in claim denial rates continues unabated. Experian Health's State of Claims 2022 report revealed that 30% of respondents experience medical claims being denied in 10-15% of cases, and 42% confirm an increasing trend in denial rates from one year to the next. There is no question that the claims denial process is ripe for innovation, and that's where reducing healthcare claim denials with artificial intelligence (AI) comes in. Like many other sectors, healthcare providers are slowly but increasingly turning to automation and AI for more accurate data and better insights. The Experian Health survey shows over one-half of healthcare providers turn to AI-driven healthcare claims management software to reduce claim denials. "Adding AI in claims processing cuts 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." The current challenges in claims management High patient volumes and complex payer policies Experian Health's 2022 State of Claims survey revealed that reducing denials was a top priority for almost three-quarters of healthcare leaders. Why? High patient volumes mean there are more claims to process, and changing payer policies and insurance coverage compound an already overwhelming problem. An Sg2 report predicts that patient volume issues will continue over the next decade, with inpatient hospital volumes growing by 2%. This rise in patient numbers will require more data for claims management processing. Hospitals, often short-staffed, will have to allocate more resources to ensure claim approval and increase efforts to address claims denial. In addition to managing increasing patient volumes, keeping track of changing payer coverage and requirements has always been challenging for providers. The inconsistency of these payer rules and communication problems exacerbate the situation. Healthcare providers may need efficient solutions to keep up with these rule changes or allocate more time and resources to addressing and revising claims. Labor shortages and financial pressures According to a data brief from the American Hospital Association, the increasing rate of clinician burnout, the enduring effects of COVID-19, and ongoing strains on the healthcare workforce are compelling hospitals to recognize and tackle chronic labor shortages. Notably, 80% of healthcare leaders acknowledge that chronic staffing shortages present significant risks for their organizations. Increasing denial rates is one way these risks manifest. As the State of Claims 2022 report confirms, 30% of respondents mentioned staffing shortages significantly contribute to healthcare claim denials. Additionally, Experian Health's recent survey, Short Staffed for the Long-Term, which investigated the impact of healthcare staffing shortages, found that 70% of respondents facing staff shortages also experienced increasing denial rates. Labor shortages mean fewer hands on deck to deal with the claims processing workload, while financial pressures on hospitals mean the stakes are higher than ever to solve the problem of claim denials. Limitations and costs of manual claims processes Health payers deny hospital systems about $260 billion worth of inpatient claims annually. According to Experian Health's survey, manual processing and a lack of automation are the primary reasons for these medical claim denials. The State of Claims 2022 report found that 61% of respondents do not automate claims submission and denial prevention processes, leaving them to rely on manually processing claims. However, manual claims management tools simply cannot keep up with the complexities and data-intensive nature of claims processing. When claims processes are handled manually, healthcare workers are burdened with cumbersome tasks that could have been automated, there is a higher risk of errors that lead to claims denial, and there'll be more need to dedicate extra time and effort to appeal denied claims. These intensive steps necessary for manual claims processing drain staff resources and create opportunities for money and time waste that are eventually detrimental to the hospital's financial circumstances. How AI and automation address healthcare claim denials Automation and AI can ease the pressure by processing more claims in less time. They give providers better insights into their claims and denial data so they can make evidence-based operational improvements. AI tools achieve this by using machine learning and natural language processing (NLP) to identify and learn from data patterns and synthesize huge data swathes to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation in claims processing can complete rules-based, repetitive tasks with incredible speed and reliability that a person might not achieve. By using automation and AI in claims processing, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Tom Bonner says, "AI in healthcare claims processing maximizes the benefits of automation for better claims processing, better customer experiences and a better bottom line for healthcare providers." However, the pace of AI adoption is somewhat slower in healthcare due to legacy data management systems and data silos. As efforts to improve interoperability progress, providers will have more opportunities to deploy AI-based technology. This prediction is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for reducing claim denials with AI to help maximize reimbursements. Key benefits of AI in healthcare claims management Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software exponentially benefits claims management through its predictive, accuracy, and error-reduction capabilities. Predictive Analytics and Pattern Recognition: The benefits of AI in healthcare claims processing lie in the ability of AI-driven solutions to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can analyze patterns in historical claims data to predict future volumes and costs, so providers can plan accordingly without simply guessing at what’s to come. Error Reduction and Clean Claim Submissions: AI can also assist in identifying inaccurate claims and improve claims processing accuracy to ensure clean claim submission and efficient revenue cycle management. Case studies and real-world applications AI and automation in claims processing are helping healthcare providers overcome the challenges contributing to increasing claim denial rates. Experian Health's AI-driven and automation solutions, like AI Advantage™, enable clients to benefit from the full potential of AI and automation to minimize claim denials. How Community Medical Centers uses AI Advantage to predict and prevent healthcare claim denials Community Medical Centers (CMC), a non-profit health system in California, uses Experian Health's new solution, AI Advantage, which uses AI to prevent and reduce claim denials. Eric Eckhart, Director of Patient Financial Services, says they became early adopters to help staff keep up with the increasing rate of denials, which could no longer be managed through overtime alone. "We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with the results we're seeing now." AI Advantage reviews claims before they are submitted and alerts staff to any likely to be denied based on patterns in the organization's historical payment data and previous payer adjudication decisions. CMC finds this particularly useful for addressing two of the most common types of denials: those denied due to lack of prior authorization and those denied because the service is not covered. Billers need up-to-date knowledge of which services will and will not be covered, which is challenging with high staff turnover. AI Advantage eases the pressure by automatically detecting changes in how payers handle claims and flagging those at risk of denial so staff can intervene. This reduces the number of denials while facilitating more efficient use of staff time. Eckhart says that within six months of using AI Advantage, they saw 'missing prior authorization' denials decrease by 22% and 'service not covered' denials decrease by 18% without additional hires. Overall, he estimates that AI Advantage has helped his team save more than 30 hours a month in collector time: "Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in-house and save money. The savings have snowballed. That's really been the biggest financial impact." How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks Providence Health is a prominent health system with 56 hospitals and over 1,000 physician clinics, serving an annual patient volume of over 28 million. This magnitude of patient volume created greater issues with slow and manual payer eligibility processes and increased eligibility denials. Furthermore, in response to Epic's growing payer plan table, Providence Health sought an effective solution to merge and organize data on insurance plans, contracts, and reimbursement details and automate eligibility tracking within the system. Their search led them to Experian Health's Insurance Eligibility Verification solution. According to Emily Brown, Director of Operation Excellence, "Our search for a solution that seamlessly integrates with Epic led us to choose Experian as our preferred vendor, given their proven track record of working with Epic." Providence Health implemented Experian's Eligibility solution, including a Bad Plan Code Detection tool to catch coding errors before submission. The solution also allowed them to stay connected to over 900 payers and provide backup connectivity to over 300 additional payers for uninterrupted service. The solution's automated work queues also helped staff work more efficiently. Providence reduced denial rates, saving $18 million in potential denials in 5 months of implementing Experian's Eligibility solution. The tool also helped them find $30 million in coverage annually while reducing staff workload. How Schneck Medical Center prevents and triages denials with AI Advantage™ Schneck Medical Center delivers care to four counties in Indiana, supported by a team of over 1,000 employees, 125 volunteers, and close to 200 physicians. According to Skylar Earley, Director of Patient Financial Services, "The challenge we (Schneck Medical Center) 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." Schneck Medical Center collaborated with Experian Health to implement: AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. They aimed to use these tools to identify claims that were more likely to be denied so that the appropriate personnel could address them and clean them before sending them to payers. They also wanted to be able to identify and prioritize denials with the potential for revenue reimbursement that will impact their bottom lines. AI Advantage™ — Predictive Denials enabled team members to make informed and timely decisions before submitting claims. In the first six months of using the tool, Schneck achieved a 4.6% average monthly decrease in denials. The time spent on denials decreased by 4x, and flagged claims were resolved in 3–5 minutes rather than the previous 12–15 minutes per correction. With AI Advantage — Denial Triage, billers were able to redirect their effort on denials more likely to be reimbursed. This prioritization enables them to avoid wasting time on high-dollar claims that are unlikely to be paid. "We had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages," says Skylar Earley, Director of Patient Financial Services Steps to implementing AI in claims management AI Advantage works in two stages in claims management, reducing claims denial and addressing denied claims to prioritize those with the best value for reimbursement. Stage One: Predictive Denials Stage one is Predictive Denials, which uses machine learning to look for patterns in payer adjudications and identify undocumented rules that could result in new denials. As demonstrated by CMC and Schneck Medical Center, this helps providers prevent denials before they occur. Stage Two: Denial Triage Stage two is Denial Triage, which comes into play when a claim has been denied. This component uses advanced algorithms to identify and segment denials based on their potential value so staff can focus on reworking the denials that will impact their bottom line. Enhancing revenue cycle management with AI Embracing integrated workflows uncovers novel applications for reducing healthcare claim denials with AI and automation. AI Advantage seamlessly works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. These integrations amplify the benefits of each tool, giving healthcare providers better insights into their claims and denial data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Key differentiators In addition to its AI solutions, Experian Health offers solutions that automate claims processing to facilitate claims management and increase efficiency. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software generates accurate adjudication reports within 24 to 72 hours to speed up reimbursement. ClaimSource ranked #1 in Best in KLAS 2024, for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. Another Experian Health solution, Enhanced Claim Status, improves cash flow by responding early and accurately to denied transactions. This solution gives healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim was denied Speeds up the denials process Automates manual claims follow-ups Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims Denials Workflow Manager integrates with the Enhanced Claim Status solution to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. Using AI and automated solutions to prevent healthcare claim denials There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex, but human error plays a large part in missed opportunities and lost revenue. The revenue cycle becomes seamless with AI and automation in healthcare claims management. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI and automation-driven claims management software offers healthcare organizations a way to achieve these goals. Contact Experian Health today to prevent healthcare claim denials and improve your claims management process with AI Advantage and other denial management solutions.

Claim denials are costly to correct and resubmit. They impede revenue flow, slow down patient care delivery, contribute to poor patient experience and satisfaction, increase administrative workload and take up limited staff time and resources. While they're avoidable, Experian Health's State of Claims 2022 report shows that 30% of respondents say denials are increasing between 10-15% year over year, which costs health systems billions of dollars. Moreover, rebilling payers often proves fruitless. Despite taking up resources and staff time and productivity and slowing down healthcare delivery, reworked and resubmitted claims denials often face repeated rejection. A KFF brief on claims denial noted that even though it's uncommon for consumers to resubmit denied claims, insurers usually stick to their original decision when resubmissions occur. Unsurprisingly, preventing claims denial and streamlining the claims management process has become a pressing need for revenue cycle leaders. The report also revealed that 70% of respondents consider claims management and reducing denials as top priorities. However, the reality of a drop in claim denial rates becomes tangible only when healthcare organizations start to automate claims processes. Claim Scrubber sets the standard as a software solution that effectively reduces denial rates, by ensuring that providers submit clean claims from the start. What is Claim Scrubber? Claim Scrubber is an automated software solution that helps healthcare providers identify errors that may lead to incorrect billing and claims denials and submit clean, thorough and accurate claims every time. It reduces undercharges and denials, ensures timely billing and payments, improves staff time and productivity and increases cash flow and bottom lines. This tool is built to seamlessly complement Experian Health's other claims processing solutions, including ClaimSource® and Denial Workflow Manager. By adopting these solutions, healthcare organizations can enjoy the full range of benefits in their claims processing and management experience while benefiting from timely, uninterrupted cash flow and higher revenue. How does Claim Scrubber work? Claim Scrubber is designed to consistently and reliably help healthcare staff produce clean and accurate claims that are more likely to be approved by payers. Here's how: Claim Scrubber meticulously analyzes each line of every pre-claim to ensure accurate coding and information before submission to the claims clearinghouse. After completing the analysis, Claim Scrubber provides general and payer-relevant edits that pinpoint incorrect code combinations or other issues that could lead to claim denial. These edits are stored within the Claim Scrubber portal and can be conveniently accessed by users from their PMS and HIS. Claim Scrubber details reasons for flagging a claim so users can make appropriate corrections before submission. Claim Scrubber enables users to make edits in alignment with payer policies by using Experian Health's comprehensive database of commercial payer policies and content. Claim Scrubber also identifies when the billed amount is less than the payer-allowed amount, helping health systems catch and correct undercharges. Claim Scrubber cleans claims, making them error-free by working with the latest and most up-to-date data. Claim Scrubber is fully functional in batch mode. Claim Scrubber operates on a secure VPN connectivity feature to ensure secure and rapid responses for real-time integrations. How can Claim Scrubber help improve claims management? Claim Scrubber optimizes claims processing by providing revenue cycle decision-makers and their teams with solutions that identify potential coding and billing errors upfront, ensure error-free claims submission to payers or clearinghouses, prevent undercharges and underpayment, increase first-time pass rates and prevent costly, time-consuming rework and rebilling that may result in a second rejection. Additionally, Claim Scrubber enables healthcare organizations to comply with and meet price transparency rules by staying updated on coding variances. Users can also revise flagged claims, ensuring appropriate and accurate corrections are made with access to Experian Health's extensive commercial payer policies and content database. Claim scrubbing occurs within 2.7–3.0 seconds, ensuring speedy transaction processing that leads to faster reimbursements. Healthcare organizations can also enjoy these benefits without the hassle of needing servers, regular maintenance and downtime with Experian Health's cloud-based application. See how State of Franklin Healthcare Associates used Claim Scrubber to expedite accounts receivable (A/R) by 13% and reduced full-time employee (FTE) requirements even as claims volume grew. Read the case study Healthcare organizations that automate claims management gain advantages that benefit all stakeholders and bottom lines. Claim Scrubber enhances operational efficiency, staff productivity, resource utilization, patient experience and satisfaction and hospital cash flow and financial growth. Contact us today to learn how Experian Health's Claim Scrubber software can help your healthcare organization submit clean, thorough claims and get paid faster and more accurately. Learn more Contact us

As revenue cycle leaders continue to navigate an increasingly complex financial landscape, preventing healthcare claim denials remains the number one priority. Experian Health's State of Claims 2022 report found that 30% of respondents see claims denied 10-15% of the time, while 42% were seeing the rate of denials increase year over year. Denials in healthcare, which can be easily avoided, contribute significantly to the waste of healthcare funds. These denials cause providers to lose hundreds of billions of dollars in profits annually. This blog looks at the key questions providers should ask to get to the bottom of why healthcare claims get denied, how to prevent healthcare claim denials and ways technology can support better denial management. Why do healthcare claims get denied? The State of Claims 2022 survey revealed that the most common causes of denied claims boil down to three issues: 1. Missing or incomplete prior authorizations Health insurers use prior authorizations to determine whether a patient's treatment is medically necessary and how much they can cover. Despite being introduced to encourage delivering high-quality, cost-effective care, the authorization process has become an intimidating administrative burden for healthcare providers. Even now, many healthcare providers rely on manual paperwork to execute an already complex and tedious authorization process. This outdated approach to authorization not only consumes time and money but also creates opportunities for missing or incomplete prior authorizations, increasing claims denial rates. Unsurprisingly, 48% identified missing or incomplete prior authorizations as one of the top three reasons for denials. 2. Failure to verify provider eligibility To be eligible for reimbursement, a provider must be a participant in the proposed Medicare or Medicaid program or other private health insurance plan. Eligibility verification involves confirming a patient's insurance information and that the planned services and provider are under their plan, which is critical for successful claims approval. Failure to verify provider eligibility may lead to claims denial if an out-of-network provider provides the services. Likewise, 42% of respondents said failure to verify provider eligibility was a common reason for denials. 3. Inaccurate medical coding Accuracy is the backbone of medical coding, another administrative task indispensable to claims approval. The slightest mistake when translating patients' diagnostic and treatment information into clinical codes can result in rejected claims. Unfortunately, providers are susceptible to coding errors due to the ever-changing coding rules, especially when they do it manually or work with unreliable automation solutions. They may work with outdated or incorrect codes, leading to claims denials. The State of Claims 2022 survey revealed similar shortcomings, with 42% of respondents stating that inaccurate medical coding led to denial. Other reasons for denied claims include: Incorrect modifiers Failure to meet submission deadlines Patient information inaccuracy Missing or inaccurate claim data Not enough staff to keep up Formulary changes Changing policies Procedure changes Improperly bundled services Service not covered 6 in 10 respondents said insufficient data and analytics made identifying and resolving issues with claims submissions difficult. A similar number said a lack of automation was hindering operational improvements. The good news is that these obstacles can all be effectively addressed with the right denial management strategy and digital tools. How do claim denials affect revenue cycles? Denials can be justified as necessary to prioritize spending on high-value care, but they have heavy consequences for hospitals' financial health. As highlighted in the Journal of Managed Care & Specialty Pharmacy, the weight of denied claims adds up to about $260 billion each year. This financial burden is pushed on hospitals, who may need to classify denied claims as debt, which, among other consequences of claims denial, ultimately disrupts their revenue cycles. The ripple effect of denied and underpaid claims on hospital revenue cycles also manifests in how delayed and non-payments restrict cash flow, hampering the provider's ability to operate efficiently and deliver care effectively. Significant staff time is lost to avoidable administrative activities and rework, as claims need to be corrected and resubmitted. This creates a bottleneck in the revenue cycle, which can lead to decreased revenue and additional costs. Extra work is particularly challenging for staff already under pressure due to ongoing labor shortages. For patients, denials can cause stress and confusion around how the cost of care will be met. How can providers reduce or prevent healthcare claim denials? Since most denials result from inaccuracies that originate early in the patient journey, the solution calls for better data management in patient access and robust checks just before claims are submitted. Reducing claims errors will contribute to better claim submission and higher reimbursement rates. Here's a step-by-step guide to improving healthcare claims processing: Utilize prior authorization software to automate the prior authorization process. This software-driven solution automates inquiries and submissions using updated and stored payer data, making the prior authorization process seamless and time-efficient and resulting in higher claim approval rates. Upgrade claims technology with tools such as ClaimSource®, which helps providers manage the entire claims cycle from one platform. By automating claims processing, ClaimSource helps ensure claims are clean before being submitted. The tool creates custom work queues so staff can prioritize high-value tasks and get paid faster. Improve the claims management process and prevent healthcare claim denials with AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. Predictive Denials flags claims that are more likely to be denied before they are submitted to the payer and tracks payer rule changes, reducing denial rates. Denial Triage prioritizes and segments denials most likely to be reimbursed, leading to increased revenue. Automate line-by-line claim reviews with Claim Scrubber to eliminate errors or omissions in claims before they are submitted. Claim Scrubber makes claims management operations more efficient, resulting in less rework, administrative costs, and delays. It can also be paired with Contract Manager, so providers can audit claims before and after remittance. Use an early-and-often approach to monitoring claim status and expedite reimbursement. Enhanced Claim Status eliminates manual follow-up and helps providers react quickly to any pending, returned-to-provider, denied, or zero-pay transactions, further improving cash flow. Experian Health's ClaimSource and Contract Manager solutions were both ranked number one in their respective categories in the 2024 Best in KLAS awards What is the best way to track and manage claim denials?  Most providers rely on manual and automated processes to manage claims and denials. Shifting from manual to digital can save time, reduce errors, and increase overall efficiency. However, providers may be wary of implementing new systems due to concerns about costs, data interoperability, and the staff learning curve. For this reason, it's essential to select a denials management solution that fits the provider's unique specifications. Denials Workflow Manager eliminates manual processes and allows providers to optimize the claims process according to the metrics that matter to them. It generates work lists based on the client's specifications, such as denial category and dollar amount, and incorporates extensive data analysis capabilities to identify the root causes of denials and improve upstream processes to prevent them. It can be easily implemented as a standalone product or integrated with ClaimSource to give users access to the entire claims and denial management cycle on a single screen. Staff training on claims management The State of Claims 2022 report revealed that 46% of respondents admitted that lack of staff training was an operational challenge contributing to claims denial. Training healthcare staff in managing and preventing claim denials is one of the most worthy investments to reduce the rate of claim denials. Hospitals can provide healthcare staff with adequate ongoing training on the granular details of claims processes before and after submission and access to automated claims management solutions. Healthcare staff should also be kept up-to-date on the latest tools and strategies on denial prevention and payer rules for claims submissions to ensure payment receipt after claim submission. Engaging patients in the claims process Though patients are usually not responsible for submitting claims to payers, they are an equal third party in the claims process and can be empowered to actively participate in every stage, from submission to approval and paying copays or deductibles. Effective patient engagement can be achieved by providing patients with an accessible, all-inclusive platform to register, review, and update information related to their care and benefit plan and communicate with healthcare staff as needed. Collaborating with payers to reduce denials The quality of collaboration between payers and providers affects the seamlessness and efficiency of the claims process. Therefore, it is crucial for providers to collaborate effectively with payers, especially given the constant changes in payer policies, to ensure that they stay up-to-date with and comply with the payer claims submission requirements. In cases of claim denials, they can also manage them effectively. By working together, payers and providers can also quickly resolve denial issues, ultimately improving system efficiency. Adopting automation and AI to prevent healthcare claim denials As one of the most complex institutions today, the healthcare industry has always grappled with a critical shortage of healthcare workers, staff burnout, and wasteful medical care spending, which costs $600 billion annually in the US. Despite the potential benefits of automation and artificial intelligence (AI) to ease these burdens and save about $200 billion to $360 billion annually in healthcare spending, their adoption has been lagging and met with resistance. However, more and more healthcare stakeholders are realizing that these technologies are a principal partner in making the healthcare system more efficient, simplifying and streamlining deeply complex processes, such as claims processing. For example, Experian Health's Patient Access Curator, an AI—and robotic process automation (RPA)-driven solution that enables eligibility and coverage verification and more accurate and submission-ready claims. By performing these tasks in seconds, all in one click, Patient Access Curator has helped clients save over $1 billion in denied claims since 2020, significantly boosting their bottom lines. Another example of efficient claims technology is ClaimSource. This all-in-one claim cycle management platform, powered by automation, transmitted $632 million in claims within five days and processed $1.1 billion of claims backlog for IU Health. AI Advantage™, Experian Health's revolutionary claims management solution that offers a two-pronged approach to preventing and managing denials: AI Advantage – Predictive Denials identifies claims that are at risk of being denied, so corrections can be made before claims are sent to payers. AI Advantage – Denial Triage comes into play post-submission, reviewing patterns in denials to prioritize those with the greatest likelihood of reimbursement. Given the volume, complexity and financial impact of the current claims workload, automation and AI are critical elements in the denials management toolkit. In the State of Claims survey, more than half of respondents said they were using automated claims processing, with many using automation to keep track of payer policy changes, automate patient portal claims reviews and digitize patient registration. Despite much media furor, AI is still the domain of early adopters: only 11% of respondents said they were using AI. But while automation can effectively eliminate unnecessary manual tasks, AI is a force multiplier for denials management, offering additional predictive capabilities and “learning” from historical data to prevent denials. Client feedback to date suggests that incorporating AI-powered denial management solutions could be a game-changer for providers looking to streamline operations, prevent lost revenue and free up capacity to focus on their primary mission of delivering quality patient care. Technology solutions for managing and preventing claim denials Efficiently managing the claims process and preventing or resolving claims denial requires robust and reliable technology solutions at every stage, especially in the complex and constantly changing world of claims management, where everything hinges on accuracy. These technology solutions can be responsible for heavy lifting many administrative tasks involved in the claims processes, from accurate data capturing during patient registration and prior authorization to submission to monitoring claim status and addressing claims submission outcomes. Hospitals can adopt claims technology, such as Experian Health's Patient Access Curator, for verifying insurance eligibility and coverage with real-time patient data correction or ClaimSource®, a single platform for monitoring and managing the claims cycle in one place. Find out more about how Experian Health helps healthcare providers prevent healthcare claim denials with automation and AI.

“We are really happy with Experian. It takes away duplication of efforts and allows us to see the bigger picture. The eligibility solution works well for our team and patients.” —Emily Brown, Director of Operation Excellence at Providence Health  Challenge Providence Health is a leading health system comprising of 56 hospitals and over 1,000 physician clinics. With an annual patient volume of over 28 million, Providence strives to prioritize the well-being of their patients by providing convenient, accessible, and affordable medical services.   Because of high patient volumes, they faced issues with slow payer eligibility processes and increased eligibility denials, which meant their staff spent a lot of valuable time verifying eligibility manually.   Additionally, as Epic's payer plan table expanded, Providence Health needed an efficient way to consolidate and align the data pertaining to insurance plans, contracts, and reimbursement details. In order to streamline the process and keep their staff within the system, Providence Health sought to automate eligibility tracking.  Solution Providence Health implemented Eligibility Verification and leveraged the Bad Plan Code Detection tool, which identifies coding errors before they're submitted to payers. With this solution, the system immediately alerts users when an incorrect plan code is flagged, allowing users to fix any issues quickly and avoid costly claim rework. Additionally, integration with Epic facilitated seamless 1:1 plan mapping, and automated the creation of new coverage records in Epic based on responses received. This streamlined the process, eliminating guesswork for staff and ensuring accurate plan selection. Emily Brown, Director of Operation Excellence says, “Our search for a solution that seamlessly integrates with Epic led us to choose Experian Health as our preferred vendor, given their proven track record of working with Epic.” By working with Experian Health, Providence has uninterrupted service and connections to over 900 payers, with backup connectivity to 300 additional payers. Providence staff can utilize automated work queues fueled by response data and custom alerts, which allows them to work more efficiently.   Outcome Thanks to Eligibility Verification, Providence Health achieved the following results:  Found an average of $30 million in coverage annually   Saved $18 million due to decreased denial rates within five months  By automating eligibility checks for high patient volumes, Providence Health boosted patient satisfaction while significantly reducing staff workload. Partnering with Experian Health allowed them to identify an increased amount of active eligibility, ensuring accurate reimbursement and avoiding claim denials. Automation also eliminated time-consuming tasks, allowing staff to focus on providing better patient care.   “Checking if my insurance was accepted was a fast and friendly process. The staff even helped clarify which insurance was the right one for me since I had multiple cards.”   - Providence Health Patient  Learn more about how Eligibility Verification helps healthcare organizations access real-time insurance coverage data, improve reimbursement rates and avoid claim denials.