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Obliterate claim denials with a modernized patient access engine

Published: March 21, 2024 by Experian Health

Obliterate-claim-denials-with-a-modernized-patient-access-engine-blog

Labor shortages and the uptick in claim denials are undoubtedly putting heavy financial strain on healthcare providers. Could automated claim denial prevention help ease the pressure?

In a recent webinar, Jason Considine, Chief Commercial Officer at Experian Health, and Jordan Levitt, Co-founder at Wave HDC (recently acquired by Experian Health), discussed strategies to tackle denials head-on in the coming year. This article summarizes the key insights, including a new automated one-click denial prevention tool that shifts denials management to the front end of the revenue cycle.

5 revenue cycle challenges causing claim denials and strained margins

To start, Considine opened the webinar with a discussion of the root causes of denials. These often originate during registration, and for many providers, “registration and data integrity continue to be a problem.” A fifth of denials are attributed to just five key issues:

  • Coordination of benefits (COB) denials, which account for a major portion of denials as more patients have secondary and tertiary coverage;
  • Contingency fees, which eat up margins in exchange for information that providers should be able to obtain themselves during registration;
  • Labor costs, which can increase with labor-saving automations that push manual input downstream;
  • Epic plan mapping, which becomes increasingly complex and error-prone as payer requirements evolve;
  • Transactional pricing, where “pay-per-click” pricing models disincentivize providers from using registration tools to find patient information during registration.

These interrelated issues should be solved with one up-front revenue cycle management (RCM) solution, rather than piecemeal fixes that are implemented later. According to Considine: “Vendors tend to offer ways to solve these problems after the patient leaves, but really we should have gotten the right information right up front. Pushing problem-solving downstream means you need more people to manage these solutions, you’ve got more vendors to manage, and you end up staffing denial management departments and throwing more people at the problem.”

Shifting from denial management to denial prevention

Part of the challenge is the sheer volume of patient information that must be collected from the start. Staff interact with multiple systems to collate, check and coordinate data on eligibility, COB, Medicare Beneficiary Identifiers, demographics and coverage. Many of these data points can be points of failure if the wrong information is captured and penetrates the rest of the system.

This makes patient access the perfect place to solve the denials problem. Levitt says this is exactly what Wave HDC set out to do when they developed the technology that underpins Patient Access Curator. “The answer isn’t multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within two to thirty seconds.”

Patient Access Curator prevents denials by capturing all patient data at registration through a single click solution that returns multiple results in less than a minute. It’s fast because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer. This means data can be transferred easily between interfaces.

Levitt explained how the tool builds a “perimeter defense against bad data,” by ensuring data accuracy from the start. Bad data is less likely to propagate through the system, which reduces the risk of denials. As a result, clients using the tool have been able to reduce contingency volume by over 60%.

Introducing the next generation of smart RCM technology

Many organizations are investing in staffing to address claim denials, but this approach is not effective in the long run. Levitt described how preventing denials calls for technology that’s built for today’s challenges.

“Most tools out there are built to manage the problems of the last twenty years. But twenty years ago, we didn’t really have COB issues. Patients were either insured or uninsured. Now, some are over-insured and some are under-insured. You see more patients come in with one insurance card in their hand, but with two, three, or four other coverages. It’s much more complex. Patient Access Curator makes it simple by bundling all the transactions into one.”

The technology uses artificial intelligence, in-memory analytics, and robotic process automation to verify eligibility and COB, find and fix patient identifiers, check contact information, and generate information about the patient’s propensity to pay.

And the result? Providers can simplify denials management even as the insurance and operational landscape becomes more complex.

Watch the webinar to hear the full discussion and find out more about how Patient Access Curator helps healthcare organizations capture accurate patient information at registration with a single click.

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“Reducing denials upfront would improve our revenue, which could be channeled into current and future investments that support our mission.” —Joshua Gayman, Revenue Cycle Manager at UT Medical Center Challenge The University of Tennessee Medical Center (UT Medical Center) is a leading 710-bed acute care hospital with a rich history of exceptional patient care and award-winning services. During the pandemic, the hospital faced revenue losses of around $45 million that put serious strain on its capacity to invest in bigger and better facilities. UT Medical Center needed to find a strategy to recover some of this revenue by reducing claim denials at the point of patient registration. UT Medical Center relied on eligibility checks that often missed errors in patient registration, resulting in increased claims denials, costly reworks, and wasted staff time. The hospital urgently needed a solution to help staff identify and resolve potential patient registration errors in real time to prevent denials before they occur. Finding a more efficient way to capture accurate patient and benefits data would be essential. Proactively preventing claim denials would provide the hospital with a much-needed boost in cash collections and free up staff to focus on patient care. Solution To address its claims denials challenge, UT Medical Center partnered with Experian Health and implemented Registration QA, a solution designed to find and fix registration errors upfront. Now, when patients first arrive, front-end staff enter their data to verify insurance. If Registration QA finds an error, it alerts staff in real-time so they can resolve it within 72 hours. Alongside more than 400 alert rules curated by Experian Health, UT Medical Center also built custom alerts based on the organization's specific requirements, using demographics and benefits data. The tool easily integrates with existing workflows, and its configurable dashboard gives UT Medical Center Management detailed insights into department performance and allows staff to track trends and identify areas for improvement. This proactive approach to correcting errors significantly reduces the risk of downstream denials and helps patient registration staff take proper corrective actions for their errors without management intervention. More accurate patient registration is also better for patients, as fewer errors make for a smoother intake experience. Outcome UT Medical Center successfully optimized patient registration by using Registration QA to identify registration errors before and at the point of service, reducing denials and boosting revenue. In the 12 months after implementing Registration QA, UT Medical Center saw the following results: Now that registration errors can be identified before and at the point of service, UT Medical Center has seen initial denials drop from an average of $5 million per month in 2022 to just $1.7 million in 2023, representing a 66% decrease in average monthly initial denials value. Cash write-offs also decreased, dropping 57% from an average of $1 million to just over $400K, helping the organization keep bad debt low. Gayman notes that UT Medical Center's partnership with Experian Health was central to its success. Experian Health shared the organization's vision and provided weekly support to help realize it. They developed a customized curriculum to make sure staff were confident using Registration QA and offered insights into what was happening more widely in the industry, so UT Medical Center's team could benchmark their performance against similar organizations. Thanks to these savings, the hospital can increase its capacity to invest in new projects and deliver operational excellence, while improving patient satisfaction. Find out more about how Registration QA helps healthcare organizations minimize denials and increase cash flow through accurate patient registration. Learn more Contact us

Published: March 24, 2025 by Experian Health

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“You know when the Patient Access Curator went live because you can see it in our stock price. It helped us drive a $100 million bottom-line improvement within two quarters.” —Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences Challenge Exact Sciences is a prominent cancer diagnostics laboratory with an annual net revenue of around $2.6 billion, that's best known for its flagship cancer screening test, Cologuard. After a period of rapid growth demand for its test, Exact Sciences faced the difficult task of collecting accurate patient data and verifying insurance eligibility at scale. Anticipating a 25% growth in annual testing volumes, Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences, says the organization “needed an automated, real-time solution" to capture accurate data from the start. The company had four specific objectives: Improve the accuracy of patient insurance data to reduce errors and denials. Streamline processes to handle rising testing volumes without increasing headcount. Reduce claim denials to bring in more revenue (especially those related to eligibility and timely filing). Ensure accurate identity verification in lab settings, where patient, physician and lab data aren't unified within a single data management system. Watch the webinar: Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. Solution In need of a single solution to solve multiple challenges, Exact Sciences turned to Experian Health's Patient Access Curator. This new product provided the team with a way to run inquiries for eligibility, Medicare beneficiary identifiers, coordination of benefits, insurance discovery and demographic data with a single click. Instead of juggling multiple products and vendors, registrars would be able to capture and verify patient data in a single transaction. Through automation and machine learning, Patient Access Curator could deliver results in less than 30 seconds and help submit clean claims the first time – reducing the risk of denials even as volumes increased. Experian Health's implementation experts configured the tool to Exact Sciences' needs, integrating over 4,000 payer plans nationwide and customizing parameters for real-time eligibility checks and data validation. Experian Health also delivered staff training to support the transition to the new system. Watch the video: See how Experian Health's Patient Access Curator streamlines patient access and billing, addressing claim denials, data quality and real-time corrections to boost your business's bottom line. Outcome Thanks to Patient Access Curator, Exact Sciences achieved the following results: 15% increase in revenue per test due to accurate eligibility and fewer denials 4x business volume without increasing headcount 50% reduction in denials and major improvement in timely filings $100 million added to the bottom line in 6 months Ken Kubisty, VP of Revenue Cycle at Exact Sciences, shares how Patient Access Curator improved eligibility processes, reduced errors and more. Overall, Kubisty credits Experian Health's Patient Access Curator for helping Exact Sciences overcome critical pain points resulting from data errors and eligibility issues. Solving for bad data quality with real-time data correction freed staff from tedious manual work, ensuring faster, more accurate claims processing – all without growing headcount. After implementing Patient Access Curator, the company is ready to scale and handle growing volumes efficiently, say goodbye to late filing denials and scale smarter. For Kubisty, this highlights how technology drives efficiency and sustainable growth. Learn more about how Patient Access Curator helps patient access teams prevent claim denials by solving for bad data quality with real-time data correction. Learn more Contact us

Published: February 27, 2025 by Experian Health

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