Racing against the clock to troubleshoot billing issues, claims bottlenecks and staffing shortfalls are just part of an average day for healthcare revenue cycle managers. It's hard enough to maintain the status quo, never mind driving improvements in denial rates and net revenue. With integrated artificial intelligence (AI) and automation, many of these challenges in revenue cycle management (RCM) can be alleviated – and with just a single click. Real-time coverage discovery and coordination of benefits software reduces errors and accelerates accurate claim submissions. This eases pressure on busy RCM leaders, so they have the time to focus on improving the numbers that matter most. Top challenges in revenue cycle management Efficiency is the currency of revenue cycle management. Maximizing resources is not just about keeping dollars coming in the door but about making the best use of each team member's time and expertise. The ever-present call to “do more with less” is probably the biggest challenge. Breaking that down, some specific concerns that consume more time and resources than RCM managers would like, are: Complex billing procedures: With hundreds of health payers operating in the US, each offering different plans with different requirements, providers have their work cut out to ensure claims are coded and billed correctly. Any errors in verifying a patient's coverage, eligibility, benefits, and prior authorization requirements can lead to delays and lost revenue. More claim denials: Inaccurate patient information and billing codes guarantee a denial. Beyond the rework and revenue loss, denied claims leave patients with bills that should not be their responsibility to pay, causing confusion, frustration, and higher levels of bad debt. Garbage in, garbage out. Patient payment delays: A few years back, patients with health insurance represented about a tenth of bills marked as bad debt. Now, this group holds the majority of patient debt, according to analysts. The rise in high-deductible health plans combined with squeezed household budgets means patients are more likely to delay or default on payments. Providers must be on the lookout for ways to help patients find active coverage and plan for their bills to minimize the impact of these changes. How can AI-powered revenue cycle management solutions help? The Council for Affordable Quality Healthcare (CAQH) annual index report demonstrates how much time can be saved using software-based RCM technology. Case in point: switching from manual to automated eligibility and benefits verification could save 14 minutes per transaction. This adds up quickly when daily, monthly, and yearly transactions are factored in. Predictive analytics can be used to pre-emptively identify and resolve issues and support better decision-making, giving providers a head start on those elusive efficiency gains. Three specific examples of how automation, AI and machine learning can streamline the front-end and solve challenges in revenue cycle management are as follows: 1. Upfront insurance discovery to find and fill coverage gaps Confirming active coverage across multiple payers gives patients and providers clarity about how care will be financed. But this can be a resource-heavy process when undertaken manually. Coverage Discovery uses automation to find missing and forgotten coverage with minimal resource requirements. By unearthing previously unidentified coverage earlier in the revenue cycle, claims can be submitted more quickly for faster reimbursement and fewer write-offs.With Experian Health's recent acquisition of Wave HDC, clients now have access to faster, more comprehensive insurance verification software solution. The technology works autonomously to identify existing insurance records for patients with self-pay, unbillable, or unspecified payer status and correct any gaps in the patient's coverage information. The patient's details are updated automatically so that a claim can be submitted to the correct payer. 2. Real-time eligibility verification and coordination of benefits As it gets harder to figure out each patient's specific coverage details, it also makes sense to prioritize automated eligibility verification. Eligibility Verification uses real-time eligibility and benefits data to confirm the patient's insurance status on the spot.Similarly, Wave's Coordination of Benefits solution, now available to Experian Health clients through Patient Access Curator, integrates directly into registration and scheduling workflows to boost clean claim rates. It automatically analyzes payer responses and triggers inquiries to verify active coverage and curate a comprehensive insurance profile. This means no insurance is missed, and the benefits under each plan can be coordinated seamlessly for more accurate billing. 3. Predictive denials management to prevent back-end revenue loss Adding AI and machine learning-based solutions to the claims and denials management workflow means providers can resolve more issues pre-claim to minimize the risk of back-end denials. Use cases for AI in claims management might include: Automating claims processing to alleviate staffing shortages Reviewing documentation to reduce coding errors Using predictive analytics to increase operational efficiency Improving patient and payer communications with AI-driven bots All of these contribute to a front-loaded denials management strategy. While prevention is often better than a cure, AI can be equally effective later in the process: AI AdvantageTM arms staff with the information they need to prevent denials before they occur and work them more efficiently when they do.Whatever new challenges may pop up on the RCM horizon, AI and automation are already proving their effectiveness in helping providers save time and money. But more than that, they're giving busy RCM leaders the necessary tools to start future-proofing their systems for persistent and emerging RCM challenges. Learn more or contact us to find out how healthcare organizations can use AI and automation to manage current revenue cycle management challenges with a single click.

Healthcare is a challenging profession. Providers understand that their mission of care delivery is fueled by the revenues they capture; after all, it is the business of healthcare. However, capturing revenues through the claims management process is burdensome and complex. Denials are all too common, hampered by inefficient workflows and manual tasks. As a result, it slows down reimbursement and impacts revenue. Moving toward reliable claim acceptance requires the strategic use of automation and technology to reduce denials. These initiatives accelerate the cycle of payments, improve cash flow, and ease strains on existing staff. This article takes a deep dive into the challenges of healthcare claims processing and strategies to help providers transform the claims management process. Challenges of healthcare claims processing The healthcare claims management process desperately needs modernization and optimization. Last year, an Experian Health survey showed that three out of four providers say reducing claims denials is their top priority. What's making it so difficult for providers to get paid? The healthcare reimbursement journey Let's start with the typical claims management process. Step 1: Prior authorization The first issue is that most generally accepted standard practices in healthcare claims processing create a long journey for provider reimbursements. This journey starts even before patient care, at eligibility and preauthorization. The American Medical Association (AMA) states, “Prior authorization is a huge administrative burden for physician practices that often delays patient care.” While prior authorization may help insurance companies reduce the cost of “unnecessary” treatments, the data shows it's having the opposite effect on the providers themselves. An AMA physician survey shows that 86% of prior authorizations lead to higher overall utilization of services. The practice doesn't appear to help patients, either; the AMA says 94% of doctors report care delays related to prior authorization, and 82% say patients abandon their treatment plans due to prior authorization struggles. Step 2: Data capture The second part of healthcare claims processing begins after the patient encounter. It involves many manual tasks, often leading to errors and claim denials. Intake and billing specialists must gather data from multiple sources for coding claims, including electronic health records (EHRs), physician notes, diagnosis codes, paper files, and the patients themselves. These workflows require significant manual data entry and review, which is impacted further when codes or insurance reimbursement requirements are out-of-date in provider systems. A recent survey shows that 42% of providers report code inaccuracies, and 33% say missing or inaccurate claims data as the top reasons for rejected claims. Step 3: Processing claims denials Post-submittal, there's more work when claims bounce back. It's part of the claims management process with the most inefficiencies and friction, costing the average provider millions annually. Healthcare providers experience Experian Health survey—but that number is rising. Responses from Experian Health's State of Claims 2022 report revealed that 30% of respondents experience denials increases of 10 to 15% annually. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand the current state of claims management. Watch the video to see the results: These challenges illustrate the need for modern and optimized healthcare claims processing. With this lens in place, healthcare providers can apply more effective claims management strategies to increase claims accuracy and reimbursement and reduce denials. Innovating your claims management strategy Healthcare professionals and organizations can proactively address challenges in the claims acceptance process by implementing effective strategies to optimize revenue cycle management. This effort should include the following: A cohesive and comprehensive claims management processNew approaches to outdated claims management workflows will address gaps, inefficiencies, and errors. Upgrading to a turnkey insurance claims manager can reduce denials and speed up claims processing. Address data quality and consolidationThe sheer volume of data required for healthcare claims processing increases the risk of errors. If the data isn't accurate at the front end, it's a fast track to denial. But claims go through multiple touch points in disparate systems without a single source of control and oversight. Organizations can employ standards for data intake to reduce inaccurate or incomplete patient information and duplicates and leverage technology to aggregate data from the multiple sources needed for claims processing. Implement best practices for denial workflowsClaim denial management on the backend of healthcare claims processing is even more challenging than capturing patient data at the front end of the encounter. Managing claims denials is time-consuming, and delays reimbursements, but denial workflow technology can streamline all follow-up activities. With this support, billers have less administrative work and can stretch farther, alleviating the burden of staffing shortages. Deploy tools for analysis and prioritizationA claims management platform can automatically analyze the components of each claim. With this information, the technology can prioritize denials workloads so high-impact accounts get the most attention. Upgrade claims technology automation with artificial intelligence (AI)Providers can transform claims management with a technology update. According to the State of Claims report, almost half of organizations replaced legacy healthcare claims processing technology in the past year. A vital component of this upgrade includes expanded automation capabilities that stretch the workforce further. Solutions like AI Advantage™ can help speed up the claims management process by predicting and preventing denials. Add prior authorization softwareAnalysis suggests that healthcare could automate up to 33% of manual tasks. Research on the benefits of automation showcases its potential for decreasing errors and other reimbursement obstacles. With prior authorization software, task assignment is seamless, and AI adds even more functionality with predictive capabilities. Accelerate claim follow upMonitoring claim status is another aspect of the payment ecosystem that heavily impacts provider cash flow. Technology automates much of this workflow. Organizations can adopt functionality that eliminates manual follow-up tasks to accelerate an unwieldy process. These solutions enable providers to respond quickly to issues, enhancing productivity beyond basic ANSI 277 claims status responses. Technology is the unifying thread behind a cohesive claims management strategy for any healthcare provider struggling with a high rate of denials. While 61% of providers lack automation in the claims/denials process, increasing evidence shows these tools drive revenue cycle efficiencies that transform claims denials management. Forward-thinking organizations like Summit Medical Group Oregon—Bend Memorial Clinic (BMC) leverage Enhanced Claim Status and Claim Scrubber to achieve a 92% primary clean claims rate. Schneck Medical Center uses AI Advantage to denials by an average of 4.6% each month. Implementing effective claims management strategies Strategies rooted in reliable, practical technology transform the claims management process. Healthcare organizations benefit from AI-driven automation solutions as part of an overarching claims management strategy that streamlines workflows, reduces denials, and boosts cash flow. Experian Health offers a portfolio of provider claims management tools to help organizations realize effective claims management process improvements to get paid faster. Learn more about the No. 1 Best in KLAS 2023 Claims Management and Clearinghouse tools or contact us to see how Experian Health can help improve your claims management processes.

More than 13 million Americans have lost Medicaid coverage since continuous enrollment came to an end in April 2023. Unwinding the emergency provisions requires states to determine which individuals remain eligible for Medicaid, leading to widespread disenrollment. The Medicaid redetermination process created a major admin burden for agencies and providers, and now, the impact of that burden on patients has become clear: more than 7 million of those who lost coverage were disenrolled because of administrative processes, and not due to ineligibility. While some will find coverage elsewhere, many will be left without insurance. These coverage gaps disrupt health services with adverse effects for patients and providers. In a recent webinar, Kate Ankumah and Mindy Pankoke, Product Managers at Experian Health, reflect on the Medicaid redetermination process and discuss how providers can mitigate the effects of redetermination heading into 2024. Recap: Medicaid continuous enrollment provision timeline How does the Medicaid redetermination process work? The redetermination process, led by state agencies, involves reviewing Medicaid rosters and automatically renewing coverage for individuals that still qualify, based on benefits or other government data. When coverage cannot be confirmed automatically, states need to reach out to patients to fill in the gaps. If the individual is no longer eligible (or does not provide the necessary data), they will be removed from coverage lists. Many patients are confused about the process and may not even realize they're no longer covered, leading to delays and distress when they try to access care. This blog post breaks down the 5 things providers can do if a patient loses Medicaid coverage. 1. Tighten up insurance eligibility verification processes During the webinar discussion, Kate Ankumah explains that implementing a reliable eligibility verification tool is essential to reduce financial risk, increase revenue and streamline staff workflows: “With our Eligibility product, we connect to more than 900 payers with search optimization. Providers don't need to send the same information over and over – we'll run through the search options ourselves and find the information as quickly as possible. Then we standardize the data so front desk staff can read all the responses in the same way. We also build in alerts. A couple of clients have alerts set up for Medicaid redetermination dates that pop up if a patient is due for redetermination so the front desk staff know to have a conversation with them about it.” Eligibility also includes an optional Medicare beneficiary identifier (MBI) lookup service, to check if any patients who may have been disenrolled from Medicaid are now eligible for Medicare. 2. Find missing coverage with Coverage Discovery Providers may also want to automate the search for any active coverage that may have been overlooked. Coverage Discovery searches for possible billable government or commercial insurance to eliminate unnecessary write-offs and give patients peace of mind. Using advanced search heuristics, millions of data points and powerful confidence scoring, this tool checks for coverage across the entire patient journey. If the patient's status changes, their bill won't be sent to the wrong place. In 2021, Coverage Discovery identified previously unknown billable coverage in more than 27.5% of self-pay accounts, preventing billions of dollars from being written off. 3. Quickly identify patients who may be eligible for Medicaid and financial assistance The lack of clarity around enrollment and eligibility is disruptive for claims and collections teams. How can they handle reimbursements and billing efficiently if financial responsibility is unclear? Denial rates are already a top concern for providers, and staff cannot afford to waste time seeking Medicaid reimbursement for disenrolled patients. Patient collections also take a hit when accounts are wrongly designated as self-pay. With Patient Financial Clearance, providers can quickly determine if patients are likely to qualify for financial support, then assign them to the right financial pathway, using pre- and post-service checks. Self-pay patients can be screened for Medicaid eligibility before treatment or at the point of service, and then routed to the Medicaid Enrollment team or auto-enrolled as charity care if appropriate. Post-visit, the tool evaluates payment risk to determine the most suitable collection policy for those with an amount to pay and can set up customized payment plans based on the patient's ability to pay. Patient Financial Clearance also runs back-end checks to catch patients who have already been sent a bill but may qualify for Medicaid or provider charity programs. This helps secure reimbursement and means patients are less likely to be chased for bills they can't pay. 4. Screen and segment patients according to their propensity to pay Optimizing collections processes is always a smart move for providers, but particularly now that federal support has ended. Collections Optimization Manager uses advanced analytics to segment patient accounts based on propensity to pay and send them to the appropriate collections team. Drawing on Experian's consumer credit data, Collections Optimization Manager's segmentation models are powered by robust and proprietary algorithms. These models screen out Medicaid and charity eligibility, so collections staff focus their time on the right accounts. Case study: See how University of California San Diego Health (UCSDH) increased collections from around $6 million to over $21 million in just two years using Collections Optimization Manager. 5. Make it simpler for patients to manage and pay bills The reality is that many patients affected by the unwinding of continuous enrollment will be on low incomes. When more than half of patients say they'd struggle to pay an unexpected medical bill of $500, providers should make it easier for patients to gauge their upcoming bills. Patient Financial Advisor and PatientSimple® can help patients navigate the payment process with pre-service estimates, access to payment plans and convenient payment methods they can access on a computer or mobile device. Together, these tools can help providers manage Medicaid changes efficiently and offer extra support to patients who may be facing disenrollment. Watch the webinar to see the full discussion on how Medicaid redetermination is affecting providers and find out how Experian Health's digital solutions can help healthcare organizations quickly and easily verify insurance coverage.

For many Americans, access to healthcare is increasingly a question of affordability. There's no room for error when it comes to determining a patient's medical bill. Helping patients understand and plan for medical bills starts with calculating patient responsibility quickly and accurately. Incorrect charges, unexpected costs and confusing payment processes create poor financial experiences for patients. According to research by Experian Health and PYMNTS, patients are increasingly worried about their healthcare costs. 46% of those surveyed had canceled care after receiving a high-cost estimate, while 60% of those with out-of-pocket expenses said inaccurate estimates or an unexpected bill would prompt them to consider switching providers. As the stakes get higher, providers must reexamine how to calculate patient responsibility in medical billing so all parties are clear about who will pay for what. Providing that clarity will improve the patient experience, streamline patient collections and protect the organization from bad debt. What is patient responsibility? Responsibility for paying medical bills is apportioned between the patient who receives care, their insurance provider (if they have one), and government payers like Medicare and Medicaid (if the patient is eligible). “Patient responsibility” refers to the portion of the bill that should be paid by the patient themselves. Getting these calculations right is critical to the provider's revenue cycle. Determining patient responsibility starts during patient registration. Here, providers have their first opportunity to check that insurance details are up to date and ensure that the patient has not overlooked any active coverage. If the patient does not have coverage, they'll be liable for the whole bill (or will have to find charity assistance). If they do have insurance, the provider will liaise with their payer to check that the proposed care is covered under the patient's plan and establish any prior authorization requirements. Then, the provider can estimate how much of the cost of care should be reimbursed by the payer, and how much will fall to the patient. The amount paid by patients includes the following categories: Co-payment – this is a fixed, flat fee the patient pays toward their medical care at the time of service. If providers do not have accurate co-pay information available at the time of the visit, they may need to bill or refund the difference later. Not all health plans include co-payments, and those that do often specify exceptions. Deductible – this the total amount the patient must pay toward medical care each year before the payer contributes. For example, if a patient has a $1000 deductible, they must pay the first $1000 of medical bills that year, and any eligible costs on top of that will be covered by their payer or shared between the patient and payer. High-deductible health plans are attractive to patients who don't think they're likely to need care, as these plans often come with lower monthly premiums. However, if the patient does need care, they'll be left footing a greater portion of the bill. Coinsurance – this is the patient's share of remaining medical costs after paying their deductible. Out-of-pocket maximum – some health plans set an annual limit to the amount a patient needs to pay toward care, including co-payments, deductibles and coinsurance. Once that limit is reached, the payer will cover the remaining eligible expenses for the remainder of the period. Clearly, this is a complicated formula. To bill correctly, providers need to know whether the proposed treatment is covered by the patient's plan, how much the payer has agreed to pay for specific services, and whether individual service providers involved in the patient's care are in-network or not. Claims will only be reimbursed if all necessary coding and payer policy requirements have been met. Revenue cycle management tools to calculate patient responsibility Traditionally, providers have relied on teams of hard-working coders and billers to manually compile and review each claim. But with so many moving parts – not to mention frequent payer policy changes and staffing shortages – manual processes are no longer viable. When determining how to calculate patient responsibility in medical billing, providers should turn to automation and digital tools. This can help them augment their staff's capacity to calculate patient responsibility more efficiently and accurately and optimize patient collections. Here are a few examples of how they might do that: Automate insurance eligibility verification - Without understanding exactly what the patient's active coverage includes, providers will remain one step behind in the medical billing and claims management process. Payers are already using automation and artificial intelligence to fulfil their side of the equation, and providers cannot risk being left behind. Automating the verification process allows providers to capture up-to-date eligibility and benefits data, including the patient's co-pay and deductible amounts, to calculate the patient's responsibility pre-services. Find missing and forgotten coverage - As more patients switch health plans, more payers join the Affordable Care Act marketplace, and employer-based insurance changes, it's increasingly likely that the patient may not be 100% sure of their active coverage. With Coverage Discovery, providers can run quick, automated and repeated checks to see if any active coverage has been overlooked. This could drastically reduce the patient's responsibility, leaving them with a more affordable bill. Automate prior authorization - Many health plans require specific services to be authorized by the payer before being administered. Providers must check these requirements pre-service, or face a denied claim which could affect the patient's bill. Obtaining authorization from health plans before administering services can be slow and expensive, and often delays care. The Council for Affordable Quality Healthcare (CAQH) states that automating prior authorizations could save the medical industry $449 million per year (or 11 minutes per transaction). Automated prior authorization software gives providers real-time insights into payer requirements, so they can speed up reimbursement and give patients clarity over what they'll owe. Why use a patient cost estimator? With the necessary insurance information at their digital fingertips, providers can then use a patient responsibility pricer to calculate the patient's co-pays, deductibles and other out-of-pocket expenses. For example, Patient Payment Estimates is a web-based price transparency tool that generates personalized estimates for patients before and at the point of service. Patients get a comprehensive breakdown of what they'll owe, so they can plan for upcoming bills or even pay upfront. Patient liability estimator tools give patients more financial clarity, saving staff time and encouraging prompter payments. They're also an important compliance tool, and are specifically recommended in CMS advice on compliance with the Hospital Price Transparency Final Rule. Accelerate and streamline patient collections Early financial clarity encourages patients to pay sooner. This means it's more likely that those bills are paid in full, instead of lingering on the aged receivables list. In addition to upfront estimates, providers should make the payment process itself as easy as possible. This might include directing patients to payment plans or charity assistance, and connecting patients to convenient payment tools at any point in their healthcare journey. Inevitably, there will be some patients who simply cannot pay their bills. Collections Optimization Manager shows staff which accounts, so they don't waste time chasing the wrong accounts. By scoring and segmenting patient accounts based on the likelihood of payment, and adjusting as the patient's situation changes, Collections Optimization Manager helps providers manage resources more efficiently, while supporting a more compassionate patient financial experience. It also enables more effective use of collections agencies to minimize the cost to collect, and incorporates reporting and benchmarking tools to identify improvement opportunities. Find out how Experian Health's revenue cycle management tools can help providers calculate patient responsibility in medical billing, for a more compassionate patient experience and streamlined collections process.

What's weighing on providers' minds as we head into 2024? According to a 2023 Medical Group Management Association (MGMA) survey, an overwhelming percentage of providers are wondering how to speed up prior authorizations. The answer: automation and electronic prior authorizations. The 2023 MGMA Annual Regulatory Burden Report surveyed executives representing more than 350 group practices about the impact of federal policies and regulations. The MGMA is the nation's largest association focused on the business of medical practice management. Respondents cited a growing volume of pre-authorizations as a key challenge, along with complex coding requirements, lengthy response times, and delays in treatment. Survey results showed that prior authorizations are a pervasive issue: 89% of respondents called pre-authorizations either “very” or “extremely” burdensome. 90% said the regulatory burden has grown in the past 12 months. 92% had hired additional staff to deal with prior authorizations. 97% said patients had experienced delays or denials due to pre-authorization requirements. 97% said a reduced regulatory burden would allow resources to be reallocated toward patient care. Neeraj Joshi, Director of Product Management at Experian Health, sees the issue as complex but solvable: “Providers have to get ahead of the constant changes in regulations and payer rules, while also overcoming the operational limitations inherent in manual processes and the industry's ongoing staffing shortages,” he says. Joshi shared his perspective on the state of pre-authorizations going into 2024—and what may be ahead as providers consider automation and new technologies surrounding electronic prior authorizations. Here's where he sees the industry heading in the year to come. Q1: What feedback have you received from providers about the challenges they face, and how is this feedback shaping the development of Experian Health's solutions? “The feedback from providers is clear: They highlight the challenges of managing an increasing volume of pre-authorizations, the complexity of payer rules, and the burdens of manual data entry,” says Joshi. “This feedback has been crucial in shaping Experian Health's solutions, leading to the development of tools that automate the pre-authorization process and keep providers up-to-date with payer rules.” Technology plays a key role in helping providers take on these challenges. Case in point: Experian Health's online authorizations solution includes access to a complete payer database that stores and dynamically updates payer prior authorization requirements. Experian Health's pre-authorization Knowledgebase works together with Authorizations software to reduce the manual workload. Automated inquiries work behind the scenes without intervention to maintain a high level of accuracy that improves efficiency, drives revenue, and protects profits. “Features like the Knowledgebase and tools such as Medical Necessity, which automatically checks patient orders against payer rules, and Claims Scrubber, an automated solution that reviews and edits claims pre-submission, reduce the time and effort required to manage pre-authorizations and minimize the risk of errors,” says Joshi. “These tools address providers' specific challenges around maintaining operational efficiency and optimizing the revenue cycle as they navigate a complicated pre-authorization landscape.” Q2: Why are providers increasingly concerned about pre-authorizations now? “A number of factors are contributing,” says Joshi. “Providers' concerns about pre-authorizations have intensified due to the pandemic's impact on healthcare operations, leading to rescheduled care and uncertainties around existing authorizations. Additionally, evolving and diverse payer rules, coupled with manual, labor-intensive processes, have exacerbated these challenges.” Each of these concerns is significant by itself. Together, they create an even greater challenge to operational efficiency. “Providers are grappling with the need to adapt to these changes, often with reduced staff,” says Joshi. “This has increased the administrative burden and complexity of managing pre-authorizations. State-specific regulations, such as New York's temporary suspension of prior authorizations, have added another layer of complexity, creating a landscape where providers must continuously adapt to both national and regional policy changes.” Q3: How do regulatory changes impact the pre-authorization landscape, and how is Experian Health adapting to these changes? “Regulatory changes, including state-specific mandates and evolving payer policies, significantly impact pre-authorizations by introducing new requirements and exceptions,” Joshi explains. As of late 2023, 40 states have enacted prior authorization regulations, with the possibility of additional and amended regulations constantly looming. Additionally, the 2024 Medicare Advantage and Part D Final Rule will change pre-authorization requirements nationwide for patients with Medicare Advantage plans. Payer rules shift constantly—both in response to regulation and independent of it—creating a massive operational challenge for providers. “These constant changes necessitate a dynamic response from healthcare providers,” says Joshi. Outdated manual processes simply aren't up to the task, least of all when staffing is limited. “Experian Health helps providers adapt by continuously updating its platforms and solutions to align with the latest regulations and payer policies. This includes integrating real-time updates and automating the process of keeping track of changing requirements, thus ensuring that providers using Experian Health's solutions are always working with the most current information.” Q4: What other ways can electronic prior authorization tools help providers address current pre-authorizations challenges? “Leveraging technology to streamline and automate the pre-authorization process is the core advantage,” Joshi says. Electronic prior authorization tools, powered by AI, represent a giant leap forward.  “Adopting solutions that reduce manual workloads, such as Experian Health's Knowledgebase, and dynamic work queues that help operational teams work the exceptions and discrepancies, rather than spending their time handling every authorization transaction, can make complex processes manageable. Emphasizing back-end automation and keeping abreast of the latest payer policies are key strategies to manage increasing patient volumes effectively. “Providers can also focus on implementing patient-facing digital tools to facilitate self-service,” Joshi continues. “A greater emphasis on self-service can reduce administrative burdens without sacrificing the patient experience.” Q5: How do you see the future of patient care being impacted by electronic prior authorizations and other advancements? “The future of patient care is poised to be significantly impacted by these advancements,” Joshi says. “Streamlined and automated pre-authorizations can lead to reduced wait times for patients and more timely access to necessary treatments.” Automating the pre-authorization process and introducing new technologies to deal with an ever-evolving, ever-expanding workflow may also help providers break a difficult cycle of overwork and understaffing. “As the administrative burden on healthcare providers decreases, more resources can be allocated to direct patient care,” Joshi maintains. “This shift will not only improve the efficiency of healthcare delivery but also enhance the overall patient experience, leading to better health outcomes and higher patient satisfaction.” Learn more about how Experian Health can help your organization improve operational efficiency and drive revenue with electronic prior authorizations.

Today, U.S. healthcare providers struggle with three significant challenges affecting care delivery—each resulting from chronic healthcare workforce shortages. Ultimately, these challenges threaten the fiscal health of the country's most critical care safety nets. Over 80% of the healthcare C-suite say the chronic staffing shortage creates significant risk for their organizations. The effects of healthcare staffing shortages are severe - Experian Health's recent survey of revenue cycle leaders found these executives unanimously agreed that staffing shortages impact cash flow, patient engagement, and the work environment of their current staff. Experian Health’s new survey, Short Staffed for the Long-Term, polled 200 revenue cycle employees to determine the effects of healthcare staffing shortages on patients, the workforce, and their facilities. What did these teams say about the healthcare workforce shortage and the state of care delivery? Find out by downloading the full report. Healthcare providers experience a vicious cycle, and the effects of healthcare staffing shortages can be seen in many different areas. For example, it makes it harder for existing team members to register patients on the front end of the encounter. On the back end, revenue cycle staff face higher workloads and stress leading to preventable reimbursement claims errors and missed collections opportunities. Ultimately, that stress leads to staff turnover, exacerbating the healthcare workforce shortage. This article dives into three effects of healthcare staffing shortages and how providers can combat them. Result 1: Short-staffed providers struggle with reimbursement and cash flow. 70% of respondents who say staff shortages affect payer reimbursement also report escalating denial rates. 83% report it's harder to follow up on late payments or help patients struggling to pay their bills. Costs are up, and cash flow is down. Claims denials are increasing by 15% annually. Reimbursement rates continue to decline even as denials rise and patient debt increases. These are the revenue cycle challenges healthcare providers face on top of the chronic healthcare staffing shortage. Healthcare organizations must look for new ways to improve reimbursements while engaging patients and staff to benefit everyone involved. Experian Health's Short Staffed for the Long-Term report noted two of the most significant revenue channels for healthcare providers, claims reimbursement and collections, are experiencing significant challenges. Reimbursement denials tie up cash flow in an endless cat-and-mouse game of revenue collection. HealthLeaders termed 2023 as, “the year of reducing denials for revenue cycle.” Their statistics further reinforce Experian Health data correlating increasing denial rates with the healthcare staffing shortage. Simultaneously, healthcare providers find it harder to collect from patients. High self-pay costs lead to lower patient collection rates. One study showed patient collections declining from 76% in 2020 to 55% in 2021. Providers desperately need a more patient-centered collections process that helps these customers understand their cost obligations and payment options. Integrating automated collections solutions can also help providers do more with less. Healthcare stakeholders must collaborate to devise innovative solutions that prioritize workforce augmentation and streamline financial workflows. Technology can solve these problems by automating manual revenue cycle processes that lead to delayed reimbursements. New solutions that use artificial intelligence (AI) software can help in other areas (like claims denials) to save staff time and reduce workloads. Result 2: A lack of staff directly impacts successful patient engagement. Surveyed staff say 55% of patients experience engagement issues at scheduling and intake. 40% say patient estimates suffer, leading to potential miscommunications in credit and collections. Experian Health's The State of Patient Access, 2023: The Digital Front Door reported patients and providers believe healthcare access is worsening. 87% of providers in the survey blamed the effects of healthcare staffing shortages. Earlier data from ECRI shows patients wait longer for care, and nearly 50% of providers say access is worse. Over 100 academic studies in the past two decades confirm the correlation between poor patient health outcomes and industry staff shortages. Existing staff members may take on heavier workloads to cover gaps in patient care. The resulting fatigue can impact the quality of care delivery. When healthcare organizations are short-staffed, each team member may spend less time with patients, resulting in rushed assessments and potentially missed diagnoses. Staff shortages can impact every phase of the patient journey, beginning with patient scheduling and potentially delayed essential medical services. On the backend, patients suffer when the pressure staff members feel to work faster causes preventable errors leading to healthcare claim denials. Collections suffer, as frustrations mount, and healthcare staff waste time on patients who are simply unable to pay. The adverse effects of staffing shortages in healthcare weaken with technology to improve the patient experience at every stage of their encounter. Better technology lessens the burden of care for staff by automating mundane administrative tasks so every provider can focus on serving patients—not filling out forms. Improving patient engagement starts at the beginning of the healthcare encounter. For example, patient scheduling software can create a seamless online experience that halves appointment booking time. More than 70% of patients say they prefer the control these self-scheduling portals offer, putting access to care back in their hands. Patient payment estimation software creates much-needed healthcare price transparency, improving satisfaction by eliminating financial surprises after treatment. These solutions, combined with automated revenue cycle management software, can streamline healthcare processes and improve patient experiences. Result 3: Overwork is the norm as staff work environments decline and turnover increases. 37% of survey respondents report issues with staff burnout. 29% list the departure of experienced staff as one of their top challenges. Whether in frontend care delivery or backend revenue cycle, overworked and stressed healthcare professionals are more susceptible to making mistakes, diminishing the overall quality of the patient experience. The attention to detail, a critical component in a complex, high-stakes business, may be compromised due to the strain on the existing staff. When a healthcare organization is short-staffed, it increases the stress on the existing employees. In turn, this contributes to higher turnover rates. Job dissatisfaction and increased stress levels create a challenging work environment, perpetuating the cycle of staffing shortages. Recruiting and training new staff to fill these gaps further exacerbate the strain on existing teams. One area that is critically impacted by staffing shortages is seen in claims management, as claim denials continue to increase, which cost American healthcare providers an estimated 2.5% of their gross revenues annually. Billions of reimbursement dollars logjam in the endless cycle of claims submissions, rejections, and manual mitigations. In 2022, the cost of denials management increased by 67%. Revenue cycle staff, stretched to their limits by staffing shortages, will likely continue to make preventable mistakes during patient intake and claims submission. However, automating claims management with a solution like ClaimSource® can help lower denial rates and ease this burden.  This solution delivers increased operational efficiencies and effectiveness by prioritizing claims, payments and denials so that users can work the highest impact accounts first. Other solutions, like Claim Scrubber, can improve claim accuracy before submission, by submitting clean and accurate claims every time. These technologies enable healthcare providers to reduce claims denials while relieving some of the terrible pressure felt by their financial teams to work harder and faster. By automating clean claims submissions, healthcare organizations free up their teams to focus on taking better care of patients—and themselves. Healthcare staffing shortages + manual revenue cycle = Unsustainability What happens to a process that heavily relies on human labor—when there aren’t enough people to go around? In the case of the healthcare revenue cycle, it means staffing shortages heavily impact a hospital's ability to collect revenue. Medical Economics reports that 78% of providers still conduct patient collections with traditional paper statements or other manual processes. In an era of talent shortages, these manual processes bog down the entire organization with no relief in sight. Overwork leads to burnout, a significant problem in the industry that also contributes to staff turnover. But this is exactly how digital technology can solve the healthcare staffing shortage. While AI and automation can’t help providers find the staff they need, it can eliminate manual tasks and reduce errors that lead to more work, staff burnout, and patient care disruption. McKinsey says automation can eliminate approximately half of the activities employees now perform. It could considerably improve the work environments for revenue cycle staff, allowing them to focus on high-value tasks, and engage patients in more caring and personalized experiences. Experian Health offers providers proven technologies to increase revenue, improve patient care, and lessen the strain on existing staff, to combat the effects of healthcare staffing shortages. Contact Experian Health today to get started.

Between November 2022 and September 2023, St. Luke's University Health Network (SLUHN) saw a 22% uplift in self-pay collections, amounting to an additional $1.2 million in average monthly collections. What makes this particularly noteworthy is that they achieved this during ongoing staffing shortages. It's an encouraging result for providers facing similar challenges, so how did they do it? On a recent webinar with Experian Health, Cindy Samuels, Senior Manager of Patient Revenue Services at St. Luke's, and Rich Wade, Strategic Product Consulting Director at Experian Health (and the Patient Revenue Services team's designated consultant), share how Collections Optimization Manager and PatientDial allowed St. Luke's to automate and optimize their collections efforts. How staffing shortages wreak havoc on the collections process Revenue cycle managers are all too familiar with the downward trend in collections recoveries over the last few years, which is exacerbated by labor shortages and rising self-pay balances. In Experian Health's August 2023 survey, Short-Staffed for the Long Term, 100% of respondents said that staffing shortages had affected revenue cycle management. Many reported that resource shortages in patient collections made it harder to follow up on late payments or help patients who were struggling to pay. With six vacancies in their own Patient Revenue Services team, St. Luke's needed a way to improve efficiency. Cindy Samuels says, “more and more dollars were falling to the patient. I had a team of folks making outbound phone calls to collect outstanding dollars, but staff were leaving messages all day long and our cash wasn't increasing. Outsourcing wasn't an option that we wanted to pursue, so we looked at technology automation.” Since St. Luke's were already using Experian products in other parts of the revenue cycle, replacing their outdated call center platform with an Experian Health solution made sense. Developing a successful strategy for collecting self-pay balances To handle increasing self-pay balances with limited staff resources, St. Luke's used Collections Optimization Manager to generate a daily accounts receivable (AR) file and then screen, segment and monitor accounts so they could be managed in the most efficient way. Samuels explains: “Every active self-pay account goes through [Experian's] scrubbing system, so they're finding medical assistance, presumptive charity, deceased bankruptcy, and other types of insurance. So, we know to set those accounts aside. The rest are segmented into five segments [based on propensity to pay] so I know where to put my resources when it comes to reaching out to patients.” With the help of an Experian Health consultant, Collections Optimization Manager users can then implement specific collections strategies that are tailored to each segment. For St. Luke's, this included automating patient calls using PatientDial, a cloud-based call system that facilitates inbound, outbound and blended call environments to help collect patient balances. The combination of segmentation and automation allows St. Luke's to have multiple call campaigns running at once, so more patients can be contacted and in a way that is more likely to lead to payment. Maximizing collections by shifting focus from “high dollar” to “ability to pay” Typically, collections teams focus on aged accounts with the highest dollar amounts. Unfortunately, this can result in staff chasing accounts that are unlikely to be paid. Collections Optimization Manager's segmentation strategy means accounts are sorted according to likelihood of payment, and treated in a way that is more likely to yield results without wasting staff time. With Collections Optimization Manager and Patient Dial, patients that are more likely to pay can be allocated to an unassisted call campaign and given an automated reminder about their balance at the appropriate time. It may not make sense to have staff spend time calling patients at the other end of the spectrum who are unable to pay or even engage with the process. An automated message with information about financial assistance may be a more appropriate approach. St. Luke's focused their resources on the segments in the middle, who are likely to be engaged but may have specific issues to resolve, such as needing details of payment plans or updating a credit card. This approach has helped the team reach more patients than ever and maintain an abandon rate of below 1.2%. Samuels says, “not only have we been able to collect more cash, but we've also been able to resolve more accounts, because with segmentation we've been able to clean up the AR that don't belong in the collections world. We can also help patients go down the financial assistance road if that's what they need. So maybe not every call results in cash, but at least we've been able to speak to patients and help them resolve any questions or concerns.” Boosting staff efficiency through automation Around 90% of St. Luke's Patient Services Team work remotely. This adds a new challenge for managers, who need to be sure that staff have the information they need to work confidently and effectively, while being able to monitor workloads and maintain productivity levels. While the increase in call volumes and collections speaks to the boost in productivity, PatientDial's reporting function has made it possible to generate a scorecard for each representative to measure performance. This allowed Samuels to identify potential training needs and foster knowledge exchange, especially when remote working means staff can't simply ask the person next to them for help. Samuels says her staff have welcomed the ability to handle more calls, more efficiently, without having to redial patients several times. PatientDial provides user-friendly dashboards, so call center agents have all the necessary details at their fingertips. Staff have said they find it motivating to be able to help more patients, which is reflected in high employee satisfaction scores in St. Luke's annual employee engagement survey. A snapshot of success In addition to increasing average monthly collections by $1.7 million in a little under a year, St. Luke's has seen the following results:     “We have increased our outbound call volume by 274% since last November, so we're reaching more patients. If we're not reaching them, we're leaving more messages. The dialer has also saved 740 hours monthly because staff are no longer dialing numbers and getting nothing. And we’re using an interactive voice response (IVR) campaign for payments, so we've saved around 253 hours each month, because patients make their payment electronically over the phone with no need to speak with a representative. It was a very positive thing for us.” Cindy Samuels provides more details of their approach on the webinar, plus her tips for others who may be considering implementing Collections Optimization Manager and PatientDial in future. Watch the webinar for full details on how St. Luke's increased collections despite staffing shortages, or contact us to learn how Experian Health can help optimize your collections efforts.

Getting a claim right the first time is much less expensive than reworking it. Experian Health's 2022 State of Claims survey illustrates most claims denials result from simple human errors. Automation and claim scrubbing software help lower the burden of denied claims. But payer contract management software offers one of the most critical strategies for optimizing revenue cycle. These tools help providers maximize reimbursements throughout the lifecycle of their payer contracts.   Experian Health client OrthoTennessee, which has an 86% successful appeals rate, recovers hundreds of thousands of dollars annually by conducting contract audits and recovering underpayments with these tools. This result could extrapolate across healthcare if providers consider implementing payer contract management software.  Understanding the financial impact of denial rates Denial rates can significantly affect a healthcare provider's revenue. One study showed these administrative complexities cause $265 billion in healthcare misspending annually. Preventing claims denials should be a high-priority issue for healthcare providers. It's an untenable situation for cash-strapped healthcare providers, and by most accounts, the problem is getting worse.  Payer contract management software reduces denial rates. A well-managed contract ensures providers are reimbursed accurately and promptly, reducing denials due to billing errors or non-compliance. Individual payer contracts stipulate how and how much a healthcare provider gets paid. In addition to critical payment terms, payer contracts contain:  How many days a provider has to submit a claim  How many days the payer will take to reimburse a correctly submitted claim  The services and scope of coverage by payer  Reimbursement rates for every covered service  How to dispute a claim denial  The term of the payer contract  When to renegotiate or the notice period for a contract termination Most of these reimbursement contracts allow payer amendments. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, says, “Depending on how the contract is written, providers may receive very little notice of these changes. Without a way to systematically and efficiently monitor these agreements throughout the contract term, there is simply no way for a provider to ensure they're paid properly.” Better payer contract management can reduce denials and improve revenue collection by reducing the most common reasons for medical claim denials.  Proactive strategies for denial reduction Proactive denial reduction correlates with a better bottom line. This effort entails a multi-faceted approach with two key elements at its core: Analyzing payer contracts for pitfalls To mitigate denials effectively, healthcare providers must scrutinize payer contracts meticulously. By delving into the fine print, organizations can identify potential pitfalls and the sources of denials. Whether complex reimbursement terms, ambiguous language, or stringent coding requirements, a comprehensive contract analysis can unveil these challenges. Crafting contract strategies for denial mitigation With a deep understanding of contract nuances, providers can develop tailored strategies for denial mitigation. These strategies encompass streamlined claims submission and staff training. Additionally, organizations can engage in informed negotiations with payers to amend unfavorable reimbursement terms.  Through this fusion of contract analysis and proactive strategy development, providers can navigate the complex landscape of healthcare payer contracting with precision, ultimately reducing denials and bolstering financial stability.  Crafting comprehensive contract management strategies for denial mitigation Developing proactive strategies within payer contract management is a critical component of denial reduction.   For example, when creating payer contracts in healthcare, providers must proactively negotiate advantageous terms for their organization. These negotiations should focus on fair reimbursement rates, reasonable timeframes for claims submission, and other favorable conditions that minimize the potential for denials.  Strategies should also encompass addressing ambiguities in healthcare payer contracting. These misunderstandings lead to disputes and denials. Clarifying any vague or unclear language within the agreement ensures all parties have a shared understanding of the terms and expectations.  Finally, to mitigate denials effectively, healthcare payer contracts should align seamlessly with billing and coding practices. These contracts must reflect current industry standards and guidelines to prevent discrepancies resulting in claim rejections. Harnessing the power of payer contract management software in healthcare  Payer contract management software offers healthcare providers a powerful way to automate payer document analysis. A single provider can have 20 or more payer contracts to manage. From HMOs to PPOs, fee-for-service federal programs, third-party administrators, to ACOs and CINs—the payer list can be long. While a thorough analysis of healthcare payer contracting is essential to identify potential areas of improvement, it can be challenging to scrutinize all of these contract terms and conditions to mitigate future denial risks. But with the right software, this revenue cycle function can be a game-changer.  Payer contract management software can handle contract renewal and regulatory updates automatically, ensuring healthcare providers remain compliant. The software eliminates the hours spent manually reviewing data. Some of the benefits include:  Centralizing contracts in one location  Alerting significant milestones, such as contract renewals or changes  Automating processes and workflows  Linking contracts with provider procedures and complianc OrthoTennessee Manager of Payer Strategy, Frances Thomas, uses Experian Health's payer contract management software. She states, “The system gives us the information we need to be successful. They can't really argue with you on that.”  The role of automation in error reduction  Healthcare runs on revenue. Automation is pivotal for reducing healthcare claims errors that tie up revenue in the denials process. Automation software streamlines workflows, reducing manual intervention and the likelihood of human errors. These tools can apply across the revenue cycle, including during the payer contract management process. For example, Experian Health's payer contract management software includes Contract Manager and Contract Analysis features that can automatically:  Compare the expected payment with the actual reimbursement from payors  Maintain and manage contract terms  Pinpoint underpayments  Audit claims   Analyze claims data and the financial impact of potential changes to provider fee schedules  Highlight bulk claims for appeal en masse   OrthoTennessee highlights the importance of the ability to handle claims in bulk. Thomas says, “We had over 600 claims for one day in the wrong network. I was able to take that bulk of claims and handle those—otherwise, I was going to have to sit there and go claim by claim. It's a huge time saver to work smarter, not harder.”  Real-time verification and validation with automation Automated systems revolutionize healthcare operations by offering real-time verification and validation capabilities. Automation technology streamlines the billing process and minimizes errors that can lead to claim denials. It enhances efficiency and precision, allowing healthcare staff to allocate more time to patient care. As providers embrace automation, they can expect increased accuracy and financial stability. RevCycleIntelligence estimates the healthcare industry could save nearly 41%, or nearly $25 billion, of the $60 billion they spend annually by fully automating administrative transactions. But payers also stand to benefit; McKinsey says administrative automation could shave 30% off insurance claims processing costs.  Seamless integration of automation with payer contracts  Integrating automation tools with payer contracts in healthcare enhances efficiency. Integration ensures contract terms are consistently applied throughout the claims lifecycle, reducing denials. Interoperability between these platforms also improves the payer-provider relationship by increasing communication and streamlining processes.   Cross-platform integration creates two-way accountability that's a win/win for both provider and payer. It's a transformative step in healthcare revenue cycle management that could:  Streamline claims submission, verification, and adjudication  Continuously monitor claims for contract adherence and correct problems before they lead to denials  Reduce human errors  Apply advanced analytics to identify trends and patterns   Improve contract negotiations with data-driven decision-making  Lower administrative costs  Navigating challenges and embracing payer contract management software Healthcare providers face numerous challenges in revenue cycle management, especially when handling intricate payer contracts and the need for standardized handling of these documents. These challenges create scenarios where providers underbill or are underpaid for services, in addition to tying up revenue in denials management. Becker's Hospital Review reports providers lose up to 3% of their revenue from underpayments. Plus, the insurance industry isn't immune to making mistakes; the AMA says the claims processing error rate of public and private payers is more than 19%. By harnessing the power of technology, healthcare providers can streamline complex payer contracts and standardize how providers handle these agreements. For example:  To expedite negotiations, modeling tools within payer contract management software offer claim scenarios that help providers negotiate better rates from payers.  These systems provide real-time feedback through smart log messages, enhancing staff training and refining registration best practices.   Most healthcare organizations lack the time and resources to closely monitor payer contracts. When these agreements are on auto-renewal, it's easy to forget their importance. Payer contract management software helps these organizations wring the maximum amount out of these revenue streams. Embracing Experian Health's payer Contract Management software Experian Health's healthcare payer contract management software offers a comprehensive contract management solution that can substantially lower denial rates. By adopting this software, providers can maximize revenue potential and streamline their revenue cycle. Importantly, healthcare providers can implement payer contract management tools without adding staff or conducting major process improvements. This software is the one tool organizations need to ensure they don't leave revenue on the table. Learn more or contact us to speak to our experts.

Like many other sectors, healthcare providers are increasingly turning to automation and artificial intelligence (AI) to get more accurate data and better insights. However, the pace of change 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 in innovative ways. This is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for AI to help maximize reimbursements. This article looks how AI and automation can help providers address the problem of growing denials, and how Experian Health's new solution, AI Advantage™, is helping one particular provider use AI to reduce claim denials. Using AI and automation to address the claims challenge 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. Changing payer policies and a changing payer mix layer on complexity. Labor shortages mean fewer hands on deck to deal with the workload, while rising costs and tighter margins mean the stakes are higher than ever. Manual claims management tools simply cannot keep up, resulting in lost time and revenue. 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 patterns in data, and synthesizing huge swathes of data to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation can be used to complete rules-based, repetitive tasks with greater speed and reliability than a person might be able to achieve. Discovering new use cases for AI in claims management Providers are finding new applications for AI as utilization becomes more widespread. Some examples of different use cases include: Automating claims processing to alleviate staffing shortages: AI tools can use natural language processing (NLP) to extract data from medical records and verify accuracy before adding the information to claims forms. This saves staff significant amounts of time and effort. Augmenting staff capacity and creating an efficient working environment can also help with recruitment and retention. Reviewing documentation to reduce coding errors: AI can perform the role of a “virtual coder,” using robotic process automation and machine learning to sift through medical data and suggest the most appropriate codes before claims are submitted. Using predictive analytics to increase operational efficiency: One of the most effective ways to improve claims management is to review and learn from past performance. 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. Improving patient and payer communications with AI-driven bots: The claims process requires large amounts of data to be exchanged between providers, payers and patients. AI-driven bots can be used to take care of much of this, for example by automatically responding to payers' requests for information during medical necessity reviews, or handling basic inquiries from patients. Case study: How Community Medical Centers uses AI Advantage to predict and prevent claims 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 that are 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 turnovers. AI Advantage eases the pressure by automatically detecting changes in the way 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 any 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.” Hear Eric Eckhart of Community Medical Centers and Skylar Earley of Schneck Medical Center discuss how AI Advantage improved their claims management workflows. AI AdvantageTM: two steps to reducing claim denials AI Advantage works in two stages. Part 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, this helps providers prevent denials before they occur. Part 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 make the biggest impact to their bottom line. At CMC, denials teams had previously focused on high value claims first, but found that smaller payers sometimes made erroneous denials that could add up over time. AI Advantage helped root these out so Eckhart's team could resolve the issue with payers. Integrated workflows reveal new applications for AI and automation AI Advantage works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. In this way, AI Advantage fits into the same workflow as tools that providers may already be using, such as Claim Scrubber, Enhanced Claim Status and Denials Workflow Manager. These integrations amplify the benefits of each individual tool, giving healthcare providers better insights into their claims and denials data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Discover how AI Advantage, Experian Health's new claims management solution, can help providers use AI to reduce claim denials.