Tag: claims management

Nearly three out of four healthcare leaders said reducing claims denials was their highest priority in  Experian Health's State of Claims Report. But knowing how to reduce claim denials is difficult. According to the survey, 62% of providers said they had insufficient access to data and analytics, and 61% lacked automation to meet the challenges of healthcare claims management. New and emerging artificial intelligence (AI) tools aim to help providers overcome these hurdles. Makenzie Smith, Product Manager at Experian Health, shares her thoughts on how providers can harness AI tools to predict, prevent, and prioritize claim denials for better results—and why preventing claim denials is so critical now. Q1: What is the challenge for revenue cycle teams, specifically when it comes to managing claims denials? “Revenue cycle teams that want to optimize claims processing have to respond to shifting payer behaviors, including major changes in the volume of denials,” says Smith. “Payers have been able to outpace providers in adopting new technologies, including AI. Payers are able process claims in a matter of seconds. For revenue cycle teams, that means receiving a large volume of denials all at once, which can be overwhelming.” At the same time, keeping up with policy changes is more than a full-time job. “You may have 20 different payers, each with multiple plans and policies that each have their own reimbursement or clinical guidelines,” says Smith. None of these policies are static: “They're constantly changing, which creates a huge challenge for providers.” Finally, maintaining enough staff to manage increased volume is an uphill battle. “The number of team members handling denials has not grown in a proportional way. Quite the opposite: They're being asked to do more with less. As providers continue to struggle with staffing imbalances, the challenge is not only having somebody to actually sit in these seats, but also managing the constant training and retraining that goes along with it.” Q2: Why is effective denial management so critical for providers' success?  “By one estimate, half of our country's hospitals are operating in the red,” says Smith. “Healthcare finance professionals are under incredible pressure to maintain or increase their operating margins. Meanwhile, Experian Health data shows that most organizations operate with an initial denial rate of 10% to 15%, and that rate is increasing year over year. “Effective denials prevention and management allow providers to get paid appropriately for services they've already provided,” Smith continues. “Optimizing revenue, improving cash flow, and maintaining expenses all stack up to provide meaningful financial resources providers can use on essential investments in staffing, physician recruitment and retention; capital equipment; and the expansion of services or service areas.” Providers that can't maintain healthy margins may be at risk for acquisition. “[Providers' viability is] put at risk daily because they must fight for every dollar from payers,” says Smith. Q3: How is Experian Health helping providers leverage AI tools and technology to start leveling up their denial management strategies? “Healthcare claims management technology solutions should be helping to bring providers up to speed,” Smith says. “Experian Health has released two products powered by a machine learning technical enablement layer to the market this year. Providers that use ClaimSource® to manage their claims can add AI Advantage™ tools to improve the way they manage claim denials. “AI Advantage - Predictive Denials uses AI and the provider's historical claim and remit data on the most probable reasons for medical claim denials to predict when claims will deny, in real-time, prior to claim submission. Billing teams can review denial predictions within their existing claim review workflows,” says Smith. “The design is incredible, allowing teams a seamless workflow integration with almost zero additional training.” “When denials do occur,” Smith continues, “AI Advantage - Denial Triage provides a predictive score based on the likelihood of recovery. Many denial follow-up teams prioritize working denials based on the highest charge amount. While that seems like a logical approach, there's a better way: segmenting by likelihood of recovery to drive priority and accelerate cash flow and recovery rates.” Q4: How is AI Advantage different from using human intelligence to predict and triage claim denials? “In some ways, it's quite similar,” Smith explains. “I was a director of billing for several years before I came to Experian Health. Often, one of the more senior billers would come to me and say, 'Hey, we're starting to see a trend with this payer, or with this denial reason code. We probably need to talk to our payer representative about this.' AI Advantage uses machine learning to identify these trends with greater speed and effectiveness, system-wide and in real-time. “Without this tool, one biller could see a denial happening twice and think nothing of it, while the biller sitting next to them is experiencing the same thing. This technology compiles all of this information together and identifies the holistic picture, so everyone benefits and trends don't go undetected.” Using AI in claims processing can make human teams more productive; it may help them feel empowered as well. Schneck Medical Center saw an average 4.6% monthly reduction in denials after six months of using AI Advantage. “Our people spend hours and hours on the phone with insurance companies fighting for dollars on claims we believe [are payable],” says Skylar Earley, Director of Patient Financial Services at Schneck. “Any leg up we can give our team members is a big, big deal.” Watch the webinar to hear from Eric Eckhart of Community Regional Medical (Fresno) and Skylar Earley of Schneck Medical Center as they discuss how their organizations use AI tools for claims management. Q5: What types of denials can providers expect to prevent, versus those that will continue to be denied? “Overall, the answer depends on a few things: an organization's healthcare claims denial management processes and ability to change on the one hand, and payer requirements on the other,” Smith says. “Too often, providers say they're just playing the game that payers put forward, simply so they can get paid what they are contractually owed.  As an industry, we cannot continue to accept this as the status quo. We'll find ourselves and our communities in a worse position to access healthcare.” Organizations that are willing to adopt new technology and be agile with their denial strategies can reduce their denial rates, even in a constantly changing environment. “I've seen the most success in denial prevention with eligibility, authorization, and technical billing categories,” says Smith. “But AI and machine learning are opening the door for new potential strategies that are more effective, more efficient, and more productive.” Q6: Clearly, claim denials affect providers, but patients also have a stake here. How do denied claims interfere with a positive patient experience? “There's definitely a patient impact,” says Smith. “Medical billing is already confusing, and a lot of people just don't understand their insurance to begin with. Add in potential denials and bills that seem to keep coming for months and months before getting resolved, and patients are bound to feel frustrated. Getting claims right on the first submission solves many of these issues up front. It reduces anxiety and makes for a much better patient experience overall.” Adding AI to the claims management toolkit Understanding how to avoid claim denials is a priority with good reason: Minimizing denials can improve revenue, lighten the burden on staff, and even help maintain a positive patient experience. Marginal changes make a difference: Smith notes that an increase in denied claims from 10% to 12% at an organization with $500 million in gross patient revenue represents a $2 million impact. Adding AI tools doesn't eliminate all the challenges of managing healthcare claims, but it does help equip providers for the current environment—and the future. Learn more about how AI Advantage can help providers prevent denials, improve the likelihood of reimbursements, and prioritize denied claims for reworking more efficiently and effectively.

Payers are using automation to adjudicate healthcare claims at scale, leaving providers struggling to keep up. One major insurer was found to have denied over 300,000 claims in two months, with each one taking an average of just 1.2 seconds. Providers that continue to rely on manual claims management methods will see their margins squeezed as the denials challenge grows. The future of healthcare claims management is here - and the answer lies in artificial intelligence (AI). Providers can level the playing field by turning to AI and automation , using tools like AI Advantage™ to streamline healthcare claims management. This article summarizes a recent webinar with two early adopters, Eric Eckhart of Community Regional Medical Center (Fresno) and Skylar Earley of Schneck Medical Center, who are using the technology to prevent denials and increase collections. Small increases in claim denials can lead to major revenue loss Makenzie Smith, Product Manager for AI Advantage at Experian Health, set the stage with observations on the current state of claims management. She notes that one of the biggest challenges when it comes to denials is constantly shifting payer behavior: “So many payer decisions are now being driven by artificial intelligence. Insurers are reviewing and denying at scale using intelligent logic, leaving providers fighting harder for every dollar.” Two hypothetical scenarios illustrate the potential impact of just a 2% increase in denials, assuming other variables remained constant: In an organization with a gross patient revenue (GPR) of $500m, an increase in denials from 10% to 12% could squeeze operational margins from 3% to 2.6%, resulting in a drop in net income from $15m to $13m. In an organization with a GPR of $2000m, an increase in denials from 18% to 20% could wipe out a 0.35% margin completely, causing net income to fall from $7m to 0. Some providers are choosing to stick with their existing processes; changing course seems too risky within thin margins. But as Eric Eckhart points out, “the just-work-harder approach doesn't work anymore.” Providers need a more efficient way to sustain operating margins. How AI Advantage helps reduce denial volume and improve net collections AI technology is emerging as a better alternative to the status quo. By using automation and AI, providers can gain insights into their claims and denial data, resulting in improved financial performance, greater efficiency and improve the future of healthcare claims management. AI Advantage™ – Predictive Denials uses AI to identify claims with a high likelihood of denial based on an organization's historical payment data. This allows staff to intervene prior to claim submission. It identifies undocumented payer adjudication rules that result in new denials. It works within Experian Health's ClaimSource® solution to proactively flag at-risk claims, allowing teams to review them within their existing claims workflow. Key takeaways from 2 real-world examples of AI in healthcare claims management Eckhart and Earley share how they are approaching denial prevention in today's fast-changing claims environment. Below are the key takeaways from their conversation about how AI is helping to optimize reimbursement and support their teams: Providers need to move beyond the “just work harder” approach to claims management Eckhart says that staffing challenges were a major driver of his organization's early adoption of AI Advantage, as it became harder to manage the increasing rate of denials with existing resources: “I think we've all tried the “let's work very hard approach” and worked overtime for months on end, but that's just not a long-term solution. We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with [AI Advantage] and the results we're seeing now.” Skylar Earley agrees, saying that despite their efforts, the rate of denials stayed the same. “It's so important for us to reduce denials because costs are increasing, reimbursements are decreasing, payments are shrinking. In our smaller community, there are only so many ways to grow revenue. We've got to maximize reimbursement, however we can.” Discover how Schneck Medical Center used AI to prevent claim denials.   Seamless integration with ClaimSource® was key to staff adoption While senior leadership teams may have been on board with testing the new technology, staff members were more hesitant about the potential pitfalls of introducing a new tool. Eckhart says, “Experian were already processing our claims through Claim Scrubber, so the workflow was essentially the same. I got some pushback when I said it was AI. I think the biggest fear for my billers was that they were going to get 5000 alerts that they would have to override and ignore. But we phased it in slowly and that was a good approach.” Earley agrees: “This is probably one of the most seamless products I've seen: it's entirely in ClaimSource®. If you didn't know about it, you wouldn't know it was there. The people using the product don't toggle back and forth between screens, they don't run reports to view alerts. The product shows them what claims they need to look at.” The predictive model gives staff their time back – so savings snowball For both organizations, a big win from AI Advantage was being able to reduce denials so staff could focus on other tasks. Making better use of staff time is increasingly urgent as the growth in denied claims outpaces recruitment. Eckhart says that over the last six months, his team have saved 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.” Reducing denials with accurate predictions Eckhart and Earley report that the success of the tool comes down to the accuracy of predictions, and the fact that it uses their own data. This applies to claims submitted to commercial and government payers, including prior authorizations. For example, Schneck Medical Center is seeing an ongoing reduction in AR days, while the number of authorized outpatient visits has increased by around 2.5% since implementing the technology. In addition to improving claims management processes, AI Advantage also helps root out persistent payer errors. Eckhart says that while denials teams tend to focus on high value claims, smaller payers can sometimes make erroneous denials that add up over time. The tool brings this to light so providers can raise it with the payer and fix it going forward. The future of healthcare claims management is here Ultimately, every prevented denial means more dollars coming back to the provider, increasing their capacity to deliver high quality services. Revenue growth makes it possible to recruit more staff, reduce outsourcing, increase capital purchases, introduce new service lines, and even explore merger and acquisition strategies. Payers are already making strides in their use of AI technology and automation, but with AI Advantage, providers can process accurate claims and reduce denials at a scale and pace to match. Find out more about how AI Advantage™ is changing the future of healthcare claims management and watch the webinar to hear the full conversation on 'The Future of Claims Management. Today.'  

Compared to other industries, healthcare tends to be more resilient to economic turbulence. But the weight of the pandemic, labor shortages, rising costs and increasingly complex reimbursement structures are squeezing hospital margins. A Kaufman Hall National Hospital Flash Report in July 2023 found that many hospitals underperformed, and the gap between high-performing hospitals and those struggling continues to widen. Providers must find new and effective ways to improve revenue cycle management, should any new uncertainties emerge. With pressure mounting to increase efficiency and reduce expenses, more providers are turning to automation and artificial intelligence (AI) to eliminate unnecessary manual work and optimize revenue cycle management processes. For example, Stanford Health Care leveraged automation to reduce their cost to collect. Banner Health improved patient collections with transparent price estimates. Schneck Medical Center zeroed in on claims management and incorporated AI to reduce denials. In the face of a cashflow crunch, healthcare providers increasingly turn to data-driven revenue cycle management (RCM) strategies that span the entire patient journey. This article lists six of the most effective income-generating digital RCM strategies that providers are using to maximize profits. Building blocks of a healthy revenue cycle At its core, revenue cycle management is about ensuring providers are fully reimbursed for the care they provide. The true ROI is much broader – efficient financial and administrative processes for patient billing, claims management and collections contribute to better care, satisfied patients, high-performing staff and good financial health. Realizing these benefits calls for revenue cycle processes built on three principles: Efficiency – streamlining processes to reduce resource utilization across the entire billing cycle Accuracy – ensuring all patient and claims data is correct and complete to avoid denials and delays Transparency – giving patients, providers and payers relevant and timely information, so they can act with confidence in each financial transaction. To achieve this, providers are moving away from slow, costly manual systems. Digital RCM tools are becoming non-negotiable. 6 data-driven strategies for effective revenue cycle management 1. Increase efficiency in patient access Revenue cycle management starts when the patient books their appointment and ends when the final bills are settled. Claim denials and delayed payments often arise from data errors and miscommunications in the early stages of the patient journey, which means patient scheduling and registration processes are critical to streamline RCM. With automated, data-driven patient access tools, providers can simplify tasks across the patient journey, so patients can move from one stage to the next with as little friction as possible. Fewer errors mean delays and disappointment are more easily avoided. Automated registration and online self-scheduling can also lead to savings through more efficient use of staff time and reducing the number of appointment no-shows. Experian Health clients find that online tools allow them to make relatively minor adjustments to their workflows, with a major impact on productivity. 2. Deliver accurate and timely patient billing Patients want the payment process to be as painless as possible. In multiple surveys, Experian Health has found that patients are worried about the cost of care, while 63% of providers believe patients frequently postpone care because of cost concerns. Clear, comprehensive estimates, billing and collections practices can make it easier for patients to navigate their financial journey. And with the end of continuous Medicaid enrollment, it's likely that more patients will find themselves unsure of their coverage situation, and in need of greater support to manage the financial process. For Stanford Health, the key to improving revenue cycle management centered around patient billing and collections. To achieve the dual goals of improving the patient experience and increasing collections, they used data-driven insights and automation to remove uncollectible accounts, prioritize accounts with a high propensity to pay, find missing coverage and reduce the manual workload. Collections Optimization Manager helped Stanford Health identify the best possible collections strategy, by scoring and segmenting patient accounts with the highest propensity to pay. Coverage Discovery® supplemented this strategy by checking for any unidentified primary, secondary or tertiary coverages that can potentially reduce self-pay amounts and avoidable charity designations. As a result, Stanford Health achieved a $4.1m increase in average monthly payments and efficiency gains of $109k per month. 3. Provide transparent price estimates Experian Health's State of Patient Access 2023 report suggests that fewer than three in ten patients know how much their care will cost in advance, while nine in ten consider it important. Delivering accurate pre-care estimates to help patients plan for bills could therefore be an easy win to improve the patient experience and recoup more revenue. Banner Health used Patient Estimates as part of a wider strategy to improve patient collections. This solution generates detailed estimates of the patient's financial responsibility along with recommendations for payment plans and financial assistance, if appropriate. Listen in as Becky Peters, Executive Director of Patient Access at Banner Health, talks about streamlining the patient registration process and improving patient access with pre-care estimates. 4. Effective claims management Perhaps the biggest opportunity to improve revenue cycle performance lies in claims and denial management, which accounts for a major proportion of wasted healthcare dollars. Summit Medical Group Oregon–BMC paired Enhanced Claim Status with Claim Scrubber to submit cleaner claims the first time and avoid lost revenue. These tools help providers submit accurate claims and monitor claim status to prevent denials and resolve issues quickly. For Summit Medical Group, this led to a 92% primary clean claims rate, and a reduction in accounts receivable days and volume by 15%. Experian Health also offers a new solution that leverages machine learning and artificial intelligence for predictive reimbursement. AI Advantage™ uses AI to predict and prevent claim denials based on historical claims data. In the first six months, this solution helped Schneck achieve a 4.6% average monthly decrease in denials and decreased time spent on denials by 4x. 5. Easy ways to pay (plus clear pricing and payment policies) How easy is it for patients to pay? This simple but important question points to another vital element of effective revenue cycle management. A compassionate and convenient patient payment experience that matches consumer experience in other industries can encourage earlier payments. Easy digital options are especially important for millennial and younger patients: research by Experian Health and PYMNTS found that 60% of younger patients are looking for digital services. Experian Health's patient-friendly payment tools are designed to help patients navigate their financial responsibilities with confidence and ease. For example, PaymentSafe® allows providers to securely collect payments anytime, anywhere, including mobile payments and patient portals. 6. Operational efficiency with automation, data and analytics RCM processes generate vast amounts of data, providing valuable insights into the organization's operational performance, revenue trends and areas for improvement. Being able to parse and translate this data into actionable insights is essential to determine the right strategies to pursue to optimize financial performance. But this in itself can be a major lift. Revenue Cycle Analytics is a web-based tool that breaks down data into actionable insights across billing, reimbursement and payer performance, presenting KPI data via comprehensive dashboards. Effective revenue cycle management strategies from start to end From labor shortages to rising costs, healthcare providers are finding creative ways to manage cash flow. While each healthcare organization’s needs and goals are different, understanding these six key strategies of successful revenue cycle management can help hospitals manage their revenue cycles more effectively and efficiently, while responding to new uncertainties. Find out more about how Experian Health helps healthcare organizations leverage automation and AI to streamline processes and boost revenue cycle performance.

Many hospitals and health systems are rethinking their responses to the growing challenge of healthcare claims management. After all, claims are becoming increasingly more complex. Payer policy edits are changing at a scale not seen before. And the legacy of the pandemic continues to take a toll on administrative workflows. In Experian Health's State of Claims survey 2022, providers reiterated the urgent need to optimize claims management – and the mountains of wasted dollars that are the by-product of preventable denials. Could artificial intelligence (AI) and machine learning (ML) be the key? What does the future of healthcare claims and AI look like? The internet is buzzing with excitement about the AI revolution, but the adoption of AI technology in healthcare has been slow, compared to other industries. Providers may be unclear about implementing AI effectively or struggle to see a route around barriers to adoption. This includes concerns around legacy systems and data interoperability. That said, the uptake of AI in healthcare shot up by 167% between 2019 and 2021, as organizations spotted opportunities to leverage new technology to reduce denials, optimize processes and identify patterns. Now, the AI genie is out of the bottle. As the trend continues to grow, providers that fail to embrace these technological advances risk falling behind as their competitors race forward. This article looks at AI's role in the future of healthcare claims management, and specifically, how it can help providers streamline claims processing, recoup more revenue and gain a competitive edge. The growing challenge of healthcare claims management In Experian Health's State of Claims Survey 2022, providers said reducing denials was their number one priority. It's clear to see why. There have been more than 100,000 payer policy changes between March 2020 and March 2022. Staffing shortages continue to put pressure on both front-and back-office teams. Increasing patient volumes and changes to insurance coverage means more claims to process – with more complexity to boot. Looking ahead, providers need to find more efficient ways to manage and utilize increasing volumes of claims data to alleviate staffing pressure, improve productivity and future-proof against unexpected events. Failure to do so could be an expensive mistake, especially when margins are already tight and the economic landscape remains shaky. Digital claims management: from process-automation to pattern-spotting The survey suggests providers are increasingly turning to automation to improve claims management, with 78% saying they were likely to replace their current solution to achieve lower denial rates in the coming year. Upgrading claims technology, automating the tracking of payer policy edits, and automating patient portal claims reviews were the top three strategies for reducing denials. Automation can generate years of ROI by executing repetitive and error-prone administrative tasks at speed and at scale. A few examples of automation in action are tools like: ClaimSource®, which manages the entire claims cycle, creating custom work queues and automating the claims process for greater efficiency and accuracy. Claim Scrubber, which automatically reviews every line of every claim to check for errors, so claims are clean the first time, prior to submission.  Denials Workflow Manager uses automation to help providers eliminate manual processes, prevent errors and increase reimbursement. AI takes this a step further, by analyzing vast amounts of information to find patterns and make predictions that support better, faster decision-making. Clarissa Riggins, Chief Product Officer at Experian Health explains why providers should embrace AI in claims and denials management: "Claims submissions and managing claims after denial are highly manual processes – and they are both extremely error-prone. AI/ML can learn from the data patterns in your claims to provide insights on where your claims are being denied most frequently. These solutions can also provide decision support to staff to help them to prioritize the work within their current claims processes, to avoid unnecessary denials in the first place and then to optimize their work to ensure a cleaner claim rate." While many providers see the potential of AI to streamline claims operations, prevent denials and accelerate reimbursement, others are hesitant to invest or are stumped by logistical barriers. Legacy technology, data compatibility issues and staff skills gaps can all put the brakes on AI implementation. But the AI train is showing no signs of slowing, and providers that fail to jump aboard could get left behind. With the right tools and an experienced vendor, implementation can be simplified. AI Advantage™ – the engine for predictive denials and denials triage Experian Health's new AI-powered denials management solution uses a two-pronged approach to predict, prevent and prioritize denials. First, AI Advantage – Predictive Denials identifies claims that may be at risk of being denied, based on analysis of historical payment data and payer decisions. This gives staff time to intervene and make any necessary amendments before the claim is submitted. The second element, AI Advantage – Denial Triage, applies an algorithm to segment denials based on the likelihood of reimbursement. This means staff can focus on high-impact resubmissions, rather than simply prioritizing high-value claims that may or may not be paid. Rob Strucker, Product SVP at Experian Health, explains that AI Advantage™ is continuously learning in real-time, so that predictions are increasingly accurate: “We look at the provider's own information for this type of service for this payer, and how those claims have been adjudicated. From that, we can score each claim in terms of its probability of being denied or claimed, and then based on that probability score, trigger an appropriate alert.” How Schneck Medical Center optimized healthcare claims management with AI Advantage™ AI Advantage™ proved to be the solution Schneck Medical Center was looking for when they set out to reduce denials. Within six months, Experian Health's AI-powered solution enabled Schneck to reduce denials by an average of 4.6% each month. Staff reported that the probability thresholds calculated by AI Advantage™ were highly accurate, facilitating a more efficient approach to reworking claims. Processing time was cut from 12 to 15 minutes to less than 5 minutes per claim. Clarissa Riggins says that AI Advantage gives staff confidence that they're spending their time on the right tasks: "When you have an algorithm that can evaluate the probability that a denial will be overturned, you can make sure that staff are working on the claims with the most potential for yield. Taken together, these solutions can help ensure that hospitals and health systems are getting paid for the good work they do in delivering care." Thanks to the tool's predictive capabilities, staff now have the insights (uncovered from within their own data) to prevent denials before claims are submitted, and to speed up rework should any be denied. As claim denials continue to increase in number and complexity and healthcare costs continue to grow, providers are feeling the impact on their revenue and margins. AI can ease the pressure by optimizing the healthcare claims management process. Find out more about how AI Advantage™ can help providers improve healthcare claims management and prevent costly claim denials.

Could the era of manual claims processing be coming to an end? Experian Health's State of Claims 2022 survey revealed that more than half of healthcare providers have embraced advanced automation, freeing up staff from time-consuming and inefficient manual tasks. Automation has dominated as the key strategy used by providers to reduce denials in the previous 12 months. This evident optimism about technology's ability to address challenges in the claims process suggests that automation is here to stay. However, while automation has cracked open the doors to more efficient claims processing, the predictive power of artificial intelligence (AI) in claims processing can unlock exponentially higher rates of reimbursement. Providers may be increasingly aware of the benefits of automation, but many have yet to step into the world of AI. This article considers the advantages to be found in layering AI technology on top of automated claims processing and looks at how two new AI solutions are helping providers reduce denials and expedite payments.  How automation helps with claims processing Healthcare organizations with automated claims processing report improvements in speed, accuracy, financial performance and patient experience. For example: Automated claims management solution ClaimSource® helped Hattiesburg Clinic in Mississippi accelerate cash flow, reduce denials to 6.1%, and expedite claims from secondary and tertiary payers. Summit Medical Group Oregon used Enhanced Claim Status and Claim Scrubber to reduce accounts receivable days by 15% and achieve a first-time pass-through rate of 92%. These tools improve efficiency across the entire claims cycle by automating repetitive tasks, executing effective workflows and generating data-driven insights into root causes of denials so staff can prioritize high-impact tasks and errors are far less likely. Industry reports corroborate these positive results: CAQH reports that the medical industry could save as much as $22.3 billion per year through further automation. Unlocking the untapped potential of AI in claims processing Despite automation's impressive results, claim denials remain a thorn in the side of many revenue cycle leaders. This is where AI can help, thanks to its ability to predict and respond to payer behavior and claims data. But while 51% of survey respondents were using automation, only 11% had introduced AI-based technology to their claims process. For the AI-curious, combining automation and AI could be a good starting point to supercharge claims processing. AI technology can predict potential issues before they even occur by analyzing claims and denials and making suggested corrections or interventions in real-time. It can also assist in identifying fraudulent claims and denials, leading to improved claims processing accuracy and revenue cycle management. By using automation and AI together, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. What does that look like in practice? More efficient and accurate claims predictions Automation can relieve staff of manual data handling activities, increasing the speed and accuracy of claim processing, from patient intake through scrubbing, submission and adjudication. AI enables staff to perform remaining tasks with greater confidence and accuracy. They no longer need to wonder, “which claim should I rework first?” – AI has the answer. Without AI, the logical approach would be to rework what appear to be the highest-value denials first. But in many cases, these aren't the ones most likely to result in reimbursement. AI can help staff prioritize by analyzing historical payment data and undocumented payer adjudication rules to flag denials that are most likely to be paid. This is exactly how AI Advantage™ – Predictive Denials works. Experian Health's new AI-based solution checks for any changes to the way payers handle denials and assesses these against previous payment behavior. Providers can set their own threshold for the probability of denial, and if the solution determines that a claim will exceed this threshold, it alerts staff so they can act quickly and decisively before the claim is submitted. Schneck Medical Center was an early adopter of this tool and used it to complement their existing claims workflow (built around ClaimSource®). Within six months, they saw average monthly denials drop by 4.6%. Predictive alerts allowed staff to focus efforts on submitting clean claims the first time, so both the number of denials and hours spent reworking them were drastically reduced. “Learning” from denials data to drive financial performance By definition, automated claims processing systems will repeat the same tasks over and over. This is great for operational efficiency but has limited capacity to handle variation. A major advantage of an AI-based solution is its capacity to “learn” and predict, so each claim can be individually assessed and directed to the most appropriate workflow. AI Advantage™ – Denial Triage uses advanced algorithms to identify and intelligently segment denials so that providers can prioritize accordingly. Just as Predictive Denials uses historical payment data to predict the claims that may be at risk of rejection, Denial Triage learns from payers' past decisions to predict the denials that are most likely to be reimbursed if reworked. Read more about Schneck Medical Center's experience with AI Advantage. How does using AI benefit healthcare staff? The use of AI in claims management can be met with different reactions: some staff are enthusiastic about the prospect of having manual tasks taken off their plate and being able to use their time more effectively. Others may be concerned about the impact of AI on jobs and recruitment. The reality is that many providers face ongoing staffing shortages, and therefore have little option but to augment their existing teams with new technology. Maintaining pre-pandemic headcounts in light of post-pandemic work patterns and budgets may not be possible. Automation and AI can resolve these short-term challenges while generating a positive ROI in the long term, as the volume and complexity of claim denials continue to grow. As noted in the State of Claims 2022 report, technology should no longer be viewed as a threat to jobs, but as a way of making life easier for staff. Automation and AI work hand in hand to execute tasks that many staff find time-consuming and laborious, leaving the more stimulating and high-value tasks for the human workforce. Improving operational performance can therefore have a positive effect on job satisfaction and retention. The integration of AI in claims processing is not about replacing human expertise, but about harnessing the power of AI-powered algorithms to enhance efficiency and minimize denials. The optimal approach lies in combining the strengths of automation, AI and staff. Automation handles repetitive processes, AI expedites decision-making, and human expertise brings contextual understanding and empathy to the process. Learn more about how Experian Health can help organizations utilize AI in healthcare claims processing with AI Advantage.

Artificial intelligence (AI) is changing the healthcare industry. From disease detection to chatbots, AI is having a significant impact on the way healthcare providers operate and deliver care to patients. Additionally, AI is transforming the revenue cycle management process by automating tasks, such as claim denials management. By leveraging AI tools, healthcare providers can reduce the time and resources required for manual claims processing, ensuring that claims are paid faster and with greater accuracy. As claim denials continue to rise by 10-15%, healthcare organizations continue to grapple with the adverse effects on their finances. That's why Experian Health created AI Advantage™ – an innovative solution that helps providers with better claim denial management. The first component, AI Advantage – Predictive Denials, proactively identifies claims that are at high risk of being denied, so providers can edit the claim prior to submission. The second component, AI Advantage – Denial Triage, steps in after claims have been denied to identify those with the highest potential for reimbursement. Schneck Medical Center is one example of a healthcare organization that has seen significant results from implementing AI Advantage. After just six months, they successfully reduced denials by an average of 4.6% each month. Corrections that would previously have taken their organization 12 to 15 minutes to rework could now be processed in under 5 minutes. With AI Advantage, healthcare organizations can improve their claim denials management processes, increase efficiency, and reduce administrative costs. The solution's ability to prevent and reduce claim denials in real time can help healthcare providers maximize revenue while delivering high-quality patient care. As healthcare organizations continue to face mounting financial pressures and staffing shortages, AI-powered solutions will be increasingly important in helping them navigate these challenges and achieve long-term success. Learn more about how healthcare organizations can begin their journey towards improving efficiency and reducing claim denials with AI Advantage.

Upgrading claims technology was the top strategy for reducing denials in 2022, according to Experian Health’s State of Claims 2022 report. The report lists the most common strategies for minimizing the risk and impact of denials, based on a survey of 200 health professionals. With more than half of providers already embracing automation, there’s broad recognition that data-driven software and streamlined workflows are key to getting more claims approved the first time and minimizing avoidable revenue loss. And as new AI-based technologies gain traction as a route to faster and richer data analytics, there are growing opportunities for providers to leverage automated claims management solutions and improve healthcare claims processing. 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: Here are 4 ways to improve healthcare claims processing, based on current practice and perceptions of claims management, and the solutions that can help providers reduce denials in 2023. 1. Upgrade claims technology More than half of survey respondents (52%) updated or replaced existing claims process technology in 2022. Healthcare executives were optimistic about using more advanced automation to improve claims processing workflows, with more than 91% saying they would “probably” or “definitely” invest in automation over the next six months. The benefits of automating healthcare claims management are well-documented. Less friction and fewer errors lead to faster and more accurate submissions, so claims are more likely to be reimbursed. Tasks can be assigned to the right specialist to make more efficient use of staff time and alleviate pressure on busy teams. Artificial intelligence (AI) takes this up a notch with additional predictive capabilities and the ability to “learn” from historical claims data. Action: Prioritize automation of data-heavy, repetitive claims management processes and leverage AI to prevent denials Recommended tool: ClaimSource® helps providers manage the entire claims cycle by creating custom work queues so staff can prioritize the most valuable tasks and speed up reimbursement. Experian Health’s new AI Advantage™ solution integrates with ClaimSource to predict and prevent denials. Pre-submission, 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. Together, these tools give staff the insights to reduce workload and minimize denials. Experian Health is pleased to announce that we've ranked #1 in Claims Management and Clearinghouse, for our ClaimSource® claims management system, according to the 2023 Best in KLAS: Software and Professional Services report. 2. Automate patient portal claims reviews For 44% of respondents, automating patient portal claims reviews were seen as an effective way to get claims right the first time. Patients can check for errors and inconsistencies in their own accounts, to prevent avoidable mistakes from ending up on claims submissions. Patients can also use portals to track the progress of claims, so they don’t need to speak to an agent. It’s more convenient for patients and reduces the call burden on staff. Action: Review digital patient access strategies to improve patient engagement Recommended tool: Safe and secure patient portals can facilitate better communication between patients and providers, smoothing out many common bumps in the claims management process. If it’s easier for patients to submit accurate and timely insurance, medical and contact information, it’ll be easier for providers to submit prompt, accurate claims. 3. Provide accurate estimates In 2022, 40% of respondents said they’d focused on providing accurate cost estimates to patients as a way of reducing claim denials. Patient estimates may not be the most obvious route to improving the denial rate, but they set the stage for successful claims management. If a provider can pull together all the necessary variables to produce accurate estimates, then they have all the pieces in place to submit clean claims. Other byproducts of reliable, upfront estimates can be seen throughout the revenue cycle: patients are more likely to pay their bills sooner and have better patient experiences. Action: Invest in pre-service patient estimates technology Recommended tool: Patient Payment Estimates allows providers to pull together complex data on each patient’s specific medical, coverage and financial circumstances into an accurate estimate of what the payer will cover and what the patient will have to pay. These accurate, upfront estimates not only improve the patient experience and make it easier for patients to understand and pay their bills, but also ensure the pieces are in place to support smoother claims management. 4. Digitize registration Finally, 39% of providers said they’d embraced digital patient registration in 2022 to tackle the problem of denials. As with patient estimates, this approach works by ensuring patient details are as accurate as possible from the start. Improving accuracy on the front-end prevents errors, delays and rework further on in the claims processing workflow. Digital and self-service registration also reduces the burden on staff. Many of the reasons providers gave for denials related to concerns around managing limited resources for everything from payer policy changes to patient admissions. Digital patient registration allows patients to complete patient access before they come in, so staff are freed up to focus on other tasks. Action: Implement an automated self-service patient registration solution Recommended tool: Registration Accelerator reduces reliance on time-consuming manual data-entry processes, which often result in denied or delayed reimbursements. Not only does it alleviate staff pressures and reduce labor costs, it also improves data quality. This solution integrates with existing health information systems, electronic medical records and eCARE NEXT®, which streamlines data entry. This will be key as providers look to reduce labor costs, increase efficiency and accelerate payments. Effective claims management requires speed, accuracy and flexibility. Find out how Experian Health’s automated claims management solutions can help providers improve healthcare claims processing and reduce denials.

Healthcare claims management is getting a much-needed infusion of technology. Artificial intelligence (AI) is the key player, utilizing vast amounts of data related to human behavior and health to forecast patterns in disease outcomes with greater precision than ever before. The same analytical power can be applied to claims data to predict and prevent denials. Using artificial intelligence for claims management is now more crucial than ever. By rooting out errors, evaluating trends and predicting payer behavior, AI helps reduce the likelihood of denied claims and maximize revenue opportunities. Staff can spend less time “treating” the effects of denied claims. But even when denials occur, AI still plays a role, quickly triaging high-value denials so staff uses their time efficiently. This two-pronged, proactive and reactive approach is captured in Experian Health's AI Advantage solution™. Using AI-powered analytics and automation, this technology helps providers predict, prevent and process denials to improve claims management and increase revenue. It's time to update claims management systems In Experian Health's State of Claims survey, nearly 3 out of 4 healthcare executives said reducing denials was their top priority. Denials are increasing in number, taking longer to process and taking a bigger bite out of provider profits. Traditional claims management strategies are no longer fit for purpose. The volume and complexity are too much for manual processes to handle, resulting in errors, time-consuming rework and lost revenue. Many providers are using automated claims management platforms to code and edit claims before they are submitted. Automation is ideal for these highly repetitive processes. Faster and more efficient claims processing increases clean claim rates and speeds up reimbursement. Experian Health's automated claims management solutions are designed with these outcomes in mind, with ClaimSource® and Contract Manager named among the best-performing claims management products in 2023, according to a KLAS report. Artificial intelligence builds on the benefits of automation, providing insights and recommendations to drive better decision-making. While automation frees staff from time-consuming, process-driven tasks, artificial intelligence allows them to perform remaining tasks at a higher level. For example, when it comes to processing denials, staff will often “guesstimate” each claim's potential for payment. They'll usually focus on reworking the highest-value denials first. AI removes the guesswork so staff can prioritize denials based on monetary value and likelihood of reimbursement, so time isn't wasted chasing higher payments that may never materialize. Using artificial intelligence for claims management can predict and prevent denials A successful denial reduction strategy starts upstream, to proactively prevent denials before they occur. AI Advantage ­– Predictive Denials uses AI to review claims before they're submitted and flag any that are likely to be denied, based on historical payment data and payer adjudication rules. The tool detects changes to the way payers handle denials, even if those aren't explicitly documented. If a claim exceeds the (customizable) threshold for probability of denial, Predictive Denials alerts the appropriate biller, who can then intervene and make corrections prior to claim submission. The benefits of this “early detection” approach include: Reducing the number of denials to be processed (and staff time spent processing them) Reducing AR days by flagging high-risk claims Improving patient satisfaction by avoiding lengthy appeals processes. After using AI Advantage – Predictive Denials for six months, Schneck Medical Center reduced average monthly denials by 4.6%. Reworking claims flagged with a predictive alert took 3–5 minutes, which was significantly quicker than before. By frontloading staff time to get claims right the first time, less effort was spent on denials. Implementation was straightforward, with no disruption to the existing claims workflow. Triaging denials for faster, more effective rework The second piece of the AI Advantage solution addresses denials that haven't been prevented. AI Advantage - Denial Triage uses advanced algorithms to identify and segment denials so staff can focus on the most profitable resubmissions. Denials are automatically triaged into five customizable categories based on likelihood of approval. Staff can rework the claims in their work queue without wondering if they're putting their effort in the right place. By automating decisions about which claims to prioritize for rework in real time, Denials Triage eliminates time spent on low-value denials and increases revenue by prioritizing high-value claims. As with Predictive Denials, this reduces the administrative burden on staff, expedites AR days, and increases patient satisfaction by reducing time to decision. Extending the automation advantage To maximize reimbursements, providers need to look at opportunities to leverage automation and artificial intelligence across the entire claims ecosystem. AI Advantage integrates with existing systems and workflows to leverage the impact of tools such as ClaimSource®. ClaimSource manages the whole claims cycle from a single online application. AI Advantage uses real-time insights generated by ClaimSource to detect patterns and predict future payer behavior. Other ways to use automation to improve claims management include: Automated claim scrubbing - Claim Scrubber uses machine learning to assess which claims have been denied in the past and why. Claims can be tagged for extra checks before being prepared for processing, to ensure likely errors have been avoided. This helps eliminate undercharges, reduce errors and minimize rework. Enhanced claim status monitoring – This helps providers keep track of existing claims. Automated status requests based on each payer's adjudication timeframe reduce manual follow-up work and allow staff to respond promptly to issues. Gathering insights into potential problems before the electronic remittance advice and explanation of benefits are processed creates time to make corrections. Using a denials workflow manager - This system automates and optimizes the denial management portion of the claims cycle, so staff can improve productivity and speed up reimbursement. With a single vendor, these tools and systems are designed to work cohesively, so there are no issues with interoperability. Data is reliable, accessible and integrated, so automation can pull from the most up-to-date and complete sources. This data can feed into proprietary machine-learning algorithms to predict and shape future performance. Experian Health's suite of automated claims management software solutions also comes with support from experienced claims-specific experts, who can help staff optimize their set-up and workflows. With the rise of AI, the healthcare industry is turning towards a more proactive approach to claim denials. Leveraging artificial intelligence for claims management can improve the overall efficiency and accuracy of healthcare claims processing, leading to fewer denials and a more seamless patient experience. Instead of waiting for denials to occur before taking remedial action, providers can use AI and automation to proactively detect errors and diagnose weaknesses in the claims process for a healthier revenue cycle. Discover how AI Advantage can help healthcare organizations predict and prevent claim denials.

“The challenge we 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.” — Skylar Earley, Director of Patient Financial Services, Schneck Medical Center Challenge Starting as a 17-bed hospital more than 100 years ago, Schneck Medical Center now serves four counties in Indiana, with a staff of more than 1,000 employees, 125 volunteers and nearly 200 physicians. The organization’s vision is to deliver excellence, lead transformation and advance health, underpinned by a patient-first philosophy. For the Patient Financial Services team at Schneck Medical Center, reworking denied healthcare claims was often time-consuming and inefficient. Billers tended to prioritize high-value claims, without knowing the probability of reimbursement. They sought a denial management solution that would reduce the risk of denied claims and minimize their impact on the revenue cycle. Solution Schneck worked with Experian Health to test two new denial management solutions that use artificial intelligence (AI) to reduce the likelihood of denials and prioritize rework to maximize reimbursement. The first, AI Advantage™ – Predictive Denials, uses AI to predict claims that have a high chance of being denied, so they can be corrected before the claim is sent to the payer. If a claim review exceeds the suggested threshold for denial probability, an alert is triggered, and the flagged claim is automatically routed to the appropriate biller. The biller investigates the alert to understand what changes are needed. This might include checking insurance eligibility, reviewing coding errors or reviewing authorization status. Once the alert is resolved, the claim can be automatically resubmitted. The second solution, AI Advantage™ – Denial Triage, prioritizes denials based on the potential for reimbursement so staff can focus recovery efforts on the right claims. The triage process starts with identifying between 2 and 10 denial segmentation categories based on likelihood of reimbursement. Schneck chose to identify 5 categories to start. Individual remits are evaluated and automatically assigned to the appropriate category, so they can be routed to the correct specialist. The tools use historical claims data and a continuously learning AI model to detect patterns in payer decisions. Staff can customize denial probability thresholds and segmentation criteria to ensure claims are routed to the correct specialist. The solutions integrate seamlessly with Schneck’s existing claims management system, ClaimSource®, and other health information workflows. Outcome After just six months, AI Advantage helped Schneck reduce denials by an average of 4.6% each month. Corrections that would previously have taken 12 to 15 minutes to rework can now be processed in under 5 minutes. Staff report that the thresholds determined by AI Advantage – Predictive Denials are highly accurate, leading to better decision-making when reworking claims prior to submission. And with AI Advantage – Denials Triage, staff feel confident that they’re focusing their attention on the right segments, rather than wasting time on high-value claims that are unlikely to be reimbursed. Skylar Earley says, “Before, we had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages.” Learn more about how AI Advantage generates insights to help healthcare organizations reduce time spent working denials and maximize reimbursement.