Tag: state of claims 2022
Claim scrubbing technology helps healthcare providers submit clean, accurate claims from the start - improving accuracy, reducing denials and maximizing reimbursements.
Automated prior authorization solutions streamline workflows, simplify management across payer systems and offer advanced features to reduce manual effort — helping providers minimize denials and improve overall efficiency.
AI and automation are transforming the claims management process. By streamlining workflows and minimizing errors, these technologies can help providers reduce denials, enhance operational efficiency and improve patient access to care.
Highlights: Healthcare claims processing is becoming more complex, putting financial stability at risk. Many organizations are turning to technology, particularly automation and artificial intelligence (AI), to improve the speed and accuracy of claims processing in healthcare Organizations that modernize their claims systems and track key performance indicators are better positioned to reduce denials and accelerate reimbursement. Healthcare claims processing is getting harder, according to Experian Health's 2024 State of Claims report. For 65% of healthcare leaders, claims management is more complex than before the pandemic. Slower reimbursements, rising denial rates and mounting administrative pressure are putting financial performance at risk. To improve speed and accuracy, many organizations are investing in technology: 45% of providers plan to invest in claims management technology in the next six months. As margins tighten, those that modernize their healthcare claims processing systems will be better equipped to stay financially strong. Understanding the current healthcare claims processing landscape Despite its central role in healthcare finance, claims processing continues to be one of the most resource-intensive and error-prone parts of the revenue cycle. Findings from the State of Claims report highlight three linked challenges that make it tough for providers to get paid promptly: rising denial rates, recurring errors that lead to even more denials, and the growing burden of rework. Denial rates are rising Claim denials are a persistent and growing issue. According to the report, 38% of healthcare leaders said that more than 10% of their claims are denied, and 11% reported denial rates over 15%. These numbers represent not just lost revenue, but significant time spent on rework and appeals. Common causes of denials The underlying reasons for denials are largely preventable. In the survey, 46% of respondents pointed to missing or inaccurate data and authorization problems as key contributors. These issues often stem from manual errors, inconsistent data entry, or gaps in communication between systems and teams. Incorrect insurance details, incomplete patient records and missing prior authorizations all lead to avoidable rejections. The cost of rework is growing As denial rates climb, so does the effort required to fix them. Almost half (48%) of respondents said they review denials manually, with three-quarters of denials handled by someone other than the person who processed the original claim. This puts extra strain on overextended revenue cycle teams on top of delayed payments. Leveraging technology for improved claims management Clearly, there's a need to reduce the manual burden. Comprehensive claims management platforms can help by automating workflows, tracking payer policies and improving claim accuracy at every stage. With claims processing tools designed to streamline decision points and flag potential issues early, revenue cycle teams can work more efficiently and sidestep disappointing financial results. For example, Denial Workflow Manager makes it easier to identify and prioritize denied claims by automating follow-up steps and assigning tasks to the right team members. Enhanced Claim Status submits automated status requests to payers, so staff can respond to pended, returned-to-provider, denied or zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed. Along with ClaimSource®, organizations can centralize claim activity and apply customizable edits and consistent formatting to reduce errors before submission. Case study: How St. Luke's Health System cut denials by 76% with Enhanced Claim Status Enhancing data accuracy for cleaner claims While many denial management strategies focus on the submission process, achieving clean claims starts much earlier in the revenue cycle. Much of the inaccurate and incomplete patient data that causes so many denials originates at registration. Patient Access Curator addresses this issue by validating critical patient and insurance information at the front end. It pulls data from multiple sources to verify insurance eligibility, confirm coverage details and flag inconsistencies in real time. By resolving errors early on, it prevents incorrect data from flowing downstream into the claim process, resulting in millions of dollars saved. As Ken Kubisty, Vice President of Revenue Cycle at Exact Sciences notes, “You know when the Patient Access Curator went live because you can see it in our stock price. It helped us drive a $100 million bottom-line improvement within two quarters.” On the back end, a tool like Claim Scrubber bolsters clean claim strategies by reviewing pre-billed claims line by line, to catch any remaining errors. Together, this front-to-back accuracy boosts first-pass payment rates and reduces the risk of costly rework. Watch the webinar: Hear how Exact Sciences and Trinity Health used Patient Access Curator to tackle denials and make major savings. Implementing automation and AI to streamline claims processing Once claims are accurate and ready for submission, automation and artificial intelligence (AI) can help organizations work smarter and faster. Nearly half (47%) of providers already using AI consider it a competitive advantage, and it's easy to see why. Predictive tools allow teams to identify which claims are at risk of denial before they are sent, so they can intervene early and avoid costly delays. Tools like AI Advantage™ use AI and machine learning to analyze patterns in claims history and payer behavior. This solution flags claims that are likely to be denied and prioritizes them for review, helping staff focus their time where it has the greatest financial impact. By identifying potential issues in advance, organizations can reduce preventable denials and improve reimbursement rates. Analyzing key performance indicators to stay ahead Even with the right tools and processes in place, consistent results require teams to keep a close eye on performance. Regularly reviewing key performance indicators gives them the insight they need to adjust strategies and stay ahead of claim issues. Metrics like denial rates, clean claim rates and days in accounts receivable show where claims are most frequently getting stuck, where errors are recurring, and where improvements are actually working. While claims processing technology can do much of the heavy lifting, it isn't a set-it-and-forget-it solution. Long-term success depends on constant fine-tuning. Organizations that stay engaged and monitor key metrics closely are better positioned to reduce denials, accelerate payments and improve financial outcomes. Experian Health consultants are also available to help guide these efforts, offering expert support and strategic advice to help claims processing teams get the most out of their investment. Find out how Experian Health's claims management tools help organizations take control of claims processing in healthcare for cleaner claims, fewer denials and faster reimbursement. Learn more Contact us
Maintaining a healthy cash flow is the only way to deliver quality patient care, invest in state-of-the-art technologies and keep daily operations running smoothly. But that's easier said than done: data errors, delayed payments, denials and staffing disruptions leave providers vulnerable to escalating admin costs and revenue leakage, with little left over to reinvest. By adopting a few key revenue cycle management (RCM) strategies, providers can sidestep these challenges and bring in more dollars. This guide summarizes five revenue cycle management best practices healthcare leaders should follow to optimize RCM workflows and promote financial stability. Key challenges in revenue cycle management Common issues that can get in the way of a healthy revenue flow include: Inaccurate patient data leading to coding errors, claim denials and billing delays Increasing numbers of denied claims generate costly rework and wasted time Payer compliance issues that are constantly changing and time-consuming to monitor Growing numbers of self-pay patients struggling to pay their bills Labor shortages increase pressure on staff and leave the door open to sub-par performance Inadequate data insights hindering management's ability to spot opportunities for improvement Rapid technological changes leave providers on the back foot if they fail to keep pace with new developments. The dream scenario would be to avoid all these potential obstacles before they do too much damage. In reality, providers will need to choose a few priority areas to troubleshoot. Check out this guide to choosing the right key performance indicators for your revenue cycle dashboard to ensure the effective implementation of RCM strategies. Revenue cycle management best practices What does a successful revenue cycle look like? For busy RCM leaders, deciding what to tackle first can be overwhelming. While there's no one-size-fits-all RCM strategy, there are a few key issues that all organizations must pay attention to. Here are five areas of best practice to factor in: 1. Streamline patient registration and insurance verification Accurate patient data is the number one factor in building a robust revenue cycle. It doesn't matter how efficient claims management and collections processes are if the data they use is flawed. Automated registration and verification tools reduce the chances of manual errors entering the system to ensure correct billing, reduce denials, and speed up reimbursement. One pitfall to watch out for is the fact that some digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility. Experian Health's latest patient access solution, Patient Access Curator, avoids this by using AI-driven technology to collect and verify patient information with a single click. 2. Automate claims submission and management According to Experian Health's State of Claims 2022 report, 62% of providers feel they lack the necessary data and analytics to identify issues in claims submission processes. A similar number believe the absence of automation prevents improvement. The CAQH Index backs this up, with the latest estimates suggesting the healthcare industry could save $18.3 billion by switching to electronic transactions. As with patient intake, there's an opportunity to leverage automation in claims management to prevent errors and delays so the organization gets paid faster. Experian Health's claims management products—ranked #1 in 2024 surveys by both KLAS and Black Book—automate each step of the claims workflow so providers can submit clean claims quickly and cut the need for time-consuming manual work. 3. Optimize denials management and appeals with AI Despite best efforts, claims denials remain a burden for many RCM teams. However, proactively understanding and addressing the root causes can help keep denials under control. There's an opportunity to go a step beyond automation and see how artificial intelligence and machine learning can help combat the denials challenge. AI AdvantageTM evaluates individual claims in real time to flag those with a high likelihood of denials based on historical payment data, so staff can intervene quickly before submission. Denials are then triaged using advanced algorithms so staff can focus on reworking denials with the greatest chance of payment, rather than wasting time on those that are never going to be approved. Eric Eckhart, Director of Patient Financial Services at Community Medical Centers in California, says that since implementing AI Advantage, “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.” Watch the webinar: Hear how Community Medical Centers and Schneck Medical Center are using AI AdvantageTM to prevent and triage denials. 4. Choose the right technology and tools for enhanced RCM The three previous revenue cycle management best practices emphasize the importance of selecting the right tools for the task. Two things to look out for when adopting a new RCM product are how well it integrates with existing tools and systems, and whether it offers meaningful insights to drive ongoing improvements. Experian Health's integrated RCM solutions are designed to fit together seamlessly, often allowing staff to view information from multiple workflows within the same dashboard. By bringing together metrics such as financial performance, billing efficiency and collections rates into one place, these tools help staff make strategic decisions about resource allocation and operational improvements. 5. Keep up with regulatory compliance Finally, ensuring compliance with regulatory requirements cannot be overlooked. The reputational and financial risks are too great. Regular training for staff on compliance issues and maintaining up-to-date knowledge of government and payer requirements will minimize the risk of penalties. Choosing RCM tools that automatically check for relevant updates can help providers stay current. Price transparency is a topical example. While the Hospital Price Transparency Rule is designed to help healthcare consumers understand healthcare costs and make more informed decisions about their care, implementation has proven tricky for providers. With the right technology and third-party support, it's much easier to stay compliant. Watch the webinar: See how Experian Health and Cleverley & Associates have partnered to help healthcare organizations navigate price transparency in 2024. Looking for more insights into revenue cycle management best practices? Contact Experian Health today to discover how our RCM solutions can transform your revenue cycle and increase cash flow year over year. Revenue cycle management solutions Contact us
As revenue cycle leaders continue to navigate an increasingly complex financial landscape, preventing healthcare claim denials remains the number one priority. Experian Health's State of Claims 2022 report found that 30% of respondents see claims denied 10-15% of the time, while 42% were seeing the rate of denials increase year over year. Denials in healthcare, which can be easily avoided, contribute significantly to the waste of healthcare funds. These denials cause providers to lose hundreds of billions of dollars in profits annually. This blog looks at the key questions providers should ask to get to the bottom of why healthcare claims get denied, how to prevent healthcare claim denials and ways technology can support better denial management. Why do healthcare claims get denied? The State of Claims 2022 survey revealed that the most common causes of denied claims boil down to three issues: 1. Missing or incomplete prior authorizations Health insurers use prior authorizations to determine whether a patient's treatment is medically necessary and how much they can cover. Despite being introduced to encourage delivering high-quality, cost-effective care, the authorization process has become an intimidating administrative burden for healthcare providers. Even now, many healthcare providers rely on manual paperwork to execute an already complex and tedious authorization process. This outdated approach to authorization not only consumes time and money but also creates opportunities for missing or incomplete prior authorizations, increasing claims denial rates. Unsurprisingly, 48% identified missing or incomplete prior authorizations as one of the top three reasons for denials. 2. Failure to verify provider eligibility To be eligible for reimbursement, a provider must be a participant in the proposed Medicare or Medicaid program or other private health insurance plan. Eligibility verification involves confirming a patient's insurance information and that the planned services and provider are under their plan, which is critical for successful claims approval. Failure to verify provider eligibility may lead to claims denial if an out-of-network provider provides the services. Likewise, 42% of respondents said failure to verify provider eligibility was a common reason for denials. 3. Inaccurate medical coding Accuracy is the backbone of medical coding, another administrative task indispensable to claims approval. The slightest mistake when translating patients' diagnostic and treatment information into clinical codes can result in rejected claims. Unfortunately, providers are susceptible to coding errors due to the ever-changing coding rules, especially when they do it manually or work with unreliable automation solutions. They may work with outdated or incorrect codes, leading to claims denials. The State of Claims 2022 survey revealed similar shortcomings, with 42% of respondents stating that inaccurate medical coding led to denial. Other reasons for denied claims include: Incorrect modifiers Failure to meet submission deadlines Patient information inaccuracy Missing or inaccurate claim data Not enough staff to keep up Formulary changes Changing policies Procedure changes Improperly bundled services Service not covered 6 in 10 respondents said insufficient data and analytics made identifying and resolving issues with claims submissions difficult. A similar number said a lack of automation was hindering operational improvements. The good news is that these obstacles can all be effectively addressed with the right denial management strategy and digital tools. How do claim denials affect revenue cycles? Denials can be justified as necessary to prioritize spending on high-value care, but they have heavy consequences for hospitals' financial health. As highlighted in the Journal of Managed Care & Specialty Pharmacy, the weight of denied claims adds up to about $260 billion each year. This financial burden is pushed on hospitals, who may need to classify denied claims as debt, which, among other consequences of claims denial, ultimately disrupts their revenue cycles. The ripple effect of denied and underpaid claims on hospital revenue cycles also manifests in how delayed and non-payments restrict cash flow, hampering the provider's ability to operate efficiently and deliver care effectively. Significant staff time is lost to avoidable administrative activities and rework, as claims need to be corrected and resubmitted. This creates a bottleneck in the revenue cycle, which can lead to decreased revenue and additional costs. Extra work is particularly challenging for staff already under pressure due to ongoing labor shortages. For patients, denials can cause stress and confusion around how the cost of care will be met. How can providers reduce or prevent healthcare claim denials? Since most denials result from inaccuracies that originate early in the patient journey, the solution calls for better data management in patient access and robust checks just before claims are submitted. Reducing claims errors will contribute to better claim submission and higher reimbursement rates. Here's a step-by-step guide to improving healthcare claims processing: Utilize prior authorization software to automate the prior authorization process. This software-driven solution automates inquiries and submissions using updated and stored payer data, making the prior authorization process seamless and time-efficient and resulting in higher claim approval rates. Upgrade claims technology with tools such as ClaimSource®, which helps providers manage the entire claims cycle from one platform. By automating claims processing, ClaimSource helps ensure claims are clean before being submitted. The tool creates custom work queues so staff can prioritize high-value tasks and get paid faster. Improve the claims management process and prevent healthcare claim denials with AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. Predictive Denials flags claims that are more likely to be denied before they are submitted to the payer and tracks payer rule changes, reducing denial rates. Denial Triage prioritizes and segments denials most likely to be reimbursed, leading to increased revenue. Automate line-by-line claim reviews with Claim Scrubber to eliminate errors or omissions in claims before they are submitted. Claim Scrubber makes claims management operations more efficient, resulting in less rework, administrative costs, and delays. It can also be paired with Contract Manager, so providers can audit claims before and after remittance. Use an early-and-often approach to monitoring claim status and expedite reimbursement. Enhanced Claim Status eliminates manual follow-up and helps providers react quickly to any pending, returned-to-provider, denied, or zero-pay transactions, further improving cash flow. Experian Health's ClaimSource and Contract Manager solutions were both ranked number one in their respective categories in the 2024 Best in KLAS awards What is the best way to track and manage claim denials? Most providers rely on manual and automated processes to manage claims and denials. Shifting from manual to digital can save time, reduce errors, and increase overall efficiency. However, providers may be wary of implementing new systems due to concerns about costs, data interoperability, and the staff learning curve. For this reason, it's essential to select a denials management solution that fits the provider's unique specifications. Denials Workflow Manager eliminates manual processes and allows providers to optimize the claims process according to the metrics that matter to them. It generates work lists based on the client's specifications, such as denial category and dollar amount, and incorporates extensive data analysis capabilities to identify the root causes of denials and improve upstream processes to prevent them. It can be easily implemented as a standalone product or integrated with ClaimSource to give users access to the entire claims and denial management cycle on a single screen. Staff training on claims management The State of Claims 2022 report revealed that 46% of respondents admitted that lack of staff training was an operational challenge contributing to claims denial. Training healthcare staff in managing and preventing claim denials is one of the most worthy investments to reduce the rate of claim denials. Hospitals can provide healthcare staff with adequate ongoing training on the granular details of claims processes before and after submission and access to automated claims management solutions. Healthcare staff should also be kept up-to-date on the latest tools and strategies on denial prevention and payer rules for claims submissions to ensure payment receipt after claim submission. Engaging patients in the claims process Though patients are usually not responsible for submitting claims to payers, they are an equal third party in the claims process and can be empowered to actively participate in every stage, from submission to approval and paying copays or deductibles. Effective patient engagement can be achieved by providing patients with an accessible, all-inclusive platform to register, review, and update information related to their care and benefit plan and communicate with healthcare staff as needed. Collaborating with payers to reduce denials The quality of collaboration between payers and providers affects the seamlessness and efficiency of the claims process. Therefore, it is crucial for providers to collaborate effectively with payers, especially given the constant changes in payer policies, to ensure that they stay up-to-date with and comply with the payer claims submission requirements. In cases of claim denials, they can also manage them effectively. By working together, payers and providers can also quickly resolve denial issues, ultimately improving system efficiency. Adopting automation and AI to prevent healthcare claim denials As one of the most complex institutions today, the healthcare industry has always grappled with a critical shortage of healthcare workers, staff burnout, and wasteful medical care spending, which costs $600 billion annually in the US. Despite the potential benefits of automation and artificial intelligence (AI) to ease these burdens and save about $200 billion to $360 billion annually in healthcare spending, their adoption has been lagging and met with resistance. However, more and more healthcare stakeholders are realizing that these technologies are a principal partner in making the healthcare system more efficient, simplifying and streamlining deeply complex processes, such as claims processing. For example, Experian Health's Patient Access Curator, an AI—and robotic process automation (RPA)-driven solution that enables eligibility and coverage verification and more accurate and submission-ready claims. By performing these tasks in seconds, all in one click, Patient Access Curator has helped clients save over $1 billion in denied claims since 2020, significantly boosting their bottom lines. Another example of efficient claims technology is ClaimSource. This all-in-one claim cycle management platform, powered by automation, transmitted $632 million in claims within five days and processed $1.1 billion of claims backlog for IU Health. AI Advantage™, Experian Health's revolutionary claims management solution that offers a two-pronged approach to preventing and managing denials: AI Advantage – Predictive Denials identifies claims that are at risk of being denied, so corrections can be made before claims are sent to payers. AI Advantage – Denial Triage comes into play post-submission, reviewing patterns in denials to prioritize those with the greatest likelihood of reimbursement. Given the volume, complexity and financial impact of the current claims workload, automation and AI are critical elements in the denials management toolkit. In the State of Claims survey, more than half of respondents said they were using automated claims processing, with many using automation to keep track of payer policy changes, automate patient portal claims reviews and digitize patient registration. Despite much media furor, AI is still the domain of early adopters: only 11% of respondents said they were using AI. But while automation can effectively eliminate unnecessary manual tasks, AI is a force multiplier for denials management, offering additional predictive capabilities and “learning” from historical data to prevent denials. Client feedback to date suggests that incorporating AI-powered denial management solutions could be a game-changer for providers looking to streamline operations, prevent lost revenue and free up capacity to focus on their primary mission of delivering quality patient care. Technology solutions for managing and preventing claim denials Efficiently managing the claims process and preventing or resolving claims denial requires robust and reliable technology solutions at every stage, especially in the complex and constantly changing world of claims management, where everything hinges on accuracy. These technology solutions can be responsible for heavy lifting many administrative tasks involved in the claims processes, from accurate data capturing during patient registration and prior authorization to submission to monitoring claim status and addressing claims submission outcomes. Hospitals can adopt claims technology, such as Experian Health's Patient Access Curator, for verifying insurance eligibility and coverage with real-time patient data correction or ClaimSource®, a single platform for monitoring and managing the claims cycle in one place. Find out more about how Experian Health helps healthcare providers prevent healthcare claim denials with automation and AI.
Many healthcare providers believe pairing “revenue cycle” with a qualifier like “predictable” is an oxymoron. From healthcare staffing shortages that slow down reimbursement tasks to increasing payer denials, financial regularity can seem like an unattainable goal for these organizations. The American Hospital Association (AHA) reports over one-half of U.S. hospitals had financial losses in 2022. Another AHA survey shows that 84% of these organizations say the cost of complying with complicated payer policies is climbing. Providers throw an excessive amount of time and staff at chasing revenue, but reimbursement complexities make for anything but smooth financial sailing. How can healthcare providers even out the ebbs and flows of the revenue cycle? Experian Health's suite of revenue cycle management (RCM) solutions can help. Revenue cycle predictability during the life of a claim When it comes to finances, U.S. healthcare providers rarely have an easy go of it. Today, the average life of a claim is anything but average. From registration to collections, hospitals established a new normal over the past decade: Widening gaps between service delivery and reimbursement. How can providers tackle this untenable situation? The answer is two-fold: with technology and at each stage of the life of a claim. Here are three ways healthcare providers can use technology to create reimbursement predictability at each stage of a claim's life. 1. Establish payment accountability at patient registration with price transparency Reimbursement problems begin at patient registration. Healthcare price transparency demands patients understand the cost of care. According to Experian Health's State of Patient Access survey, 81% of patients agreed that an accurate estimate helps them better prepare to pay for their care costs. However, only 31% of patients received a cost estimate before care. There are three significant impacts of this troubling trend: Nearly 40% of patients say they put off needed care due to cost. The number rises to 61% if the patient is uninsured. Patients can't afford to pay for needed care. Currently, 41% of U.S. adults have medical debt. An Experian Health study showed four in 10 patients spend more than they can afford on healthcare treatment. Uncompensated care causes a significant drop in healthcare provider income, which has amounted to almost $745 billion, according to the AHA. Experian Health offers several data-driven solutions to improve price transparency. These tools make it easier for patients to handle their financial responsibilities while helping providers find solutions to help ease their burdens.Patient Financial Advisor creates more accurate service estimates for patients before their procedure. The mobile-first platform offers patients a detailed cost breakdown on their preferred digital device. Patient Estimates is a web-based platform offering real-time service estimates. Blessing Health System uses the tool to provide patient estimates that are up to 90% accurate. The provider increased collections by 58% and credits the software with a 1,200% return on their investment. Patient Access Curator automatically initiates communication with payers to improve coordination of benefits and maximize return. It also automatically identifies missing or incorrect Medicare Beneficiary Identifier (MBI) numbers or errors in patient contact details. This solution also helps providers understand the patient's ability and propensity to pay, allowing these organizations to predict revenue streams after service delivery. Behind the scenes, Experian Health also automates insurance eligibility verification to unlock hidden reimbursements. This software roadmaps the correct coverage, connects to more than 900 payers and verifies insurance coverage at the time of service to improve cash flow and ease patient payment burdens. 2. Reduce claim denials by decreasing manual paperwork errors Claim denials are one of the biggest impediments to revenue cycle predictability. Providers are stuck in an endless cycle of inaccurate payer submissions, rejected claims, and rebilling, creating a chaotic chase for payment long after the service. Today, 35% of healthcare organizations report $50 million or higher in lost revenue due to claims denials. Even worse, Experian Health's State of Claims 2022 report showed that 30% of providers say denials are increasing by up to 15%. According to that data, the top three reasons for claim denials are: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Coding inaccuracies. Experian Health's Claim Scrubber software levels out provider cash flow, creating predictability amidst the chaos. The solution reviews complete claims for errors, generating actionable edits before submission. Claim Scrubber also reviews approved reimbursement rates to prevent undercharging. Transactions process within three seconds and providers reduce the need to rework claims. Experian Health's AI Advantage solution uses the power of artificial intelligence (AI) to evaluate every claim for its propensity to turn into a denial. Instead of submitting claims and hoping the payer will accept them, this solution takes the guesswork out of reimbursement for a more rational, predictable process. The software automatically scans for payer updates to reimbursement requirements that significantly contribute to claims denials. Hospitals like Schneck Medical Center use this tool to streamline the revenue cycle by preventing denials. After just six months, the provider’s denied claims reduced by an average of 4.6% each month. Claim corrections that took up to 15 minutes manually are now processed in less than five. 3. Increase collections efficiency with automation Patients trust their healthcare providers to take care of them. Providers also rely on patients to pay their bills. It's a mutually beneficial arrangement. However, it's also a problem forcing providers to walk a delicate tightrope between caring for a sick patient while still chasing payment for their services. Unfortunately, the increasing cost of healthcare leaves patients on the hook for more than $88 billion in debt. The volume of healthcare payments in arrears is staggering, causing a substantial drain on provider cash on hand. However, technology offers healthcare providers a way to improve the patient collections process. For example, Coverage Discovery impacts the revenue cycle at every stage of the claim: Before providing care, the software scans patient data to determine reimbursement coverage options from Medicaid, Medicare, and commercial insurance. It scans for active insurance 30, 60, and 90 days after care delivery. The tool scans patient data before determining whether the account moves to bad debt collections. A more robust understanding of patient payment options at every stage of claims management allows healthcare providers to forecast reimbursements more accurately, increasing the predictability of the revenue cycle. Collections Optimization Manager provides organizations with actionable insights, so that providers can segment and prioritize accounts by proprensity to pay. This solution increases patient collections by leveraging Experian's data driven segmentation models, and helps providers screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Experian Health's AI Advantage – Denial Triage prioritizes rejected claims based on their yield potential, automating workflows for claims managers so they focus first on the patients more likely to pay. This tool segments denials based on their potential value to help even out the revenue cycle with a faster rate of financial return. Denial Triage expedites A/R by increasing revenue collection per person per hour. Revenue cycles can be more predictable, but the complexities of reimbursement require technology to achieve this goal. Experian Health offers a comprehensive line of revenue cycle management solutions to help healthcare providers maximize collections and improve RCM. Find out why Experian Health ranks Best in KLAS for 2024 in the categories of Claims Management & Clearinghouse and Revenue Cycle: Contract Management, or contact us for a more predictable revenue cycle, better cash flow, and a healthier organization.
Technology has a long track record of improving patient care. But humans are now entering uncharted waters as the latest wave of digital tools impact healthcare clinical and administrative workflows. Technology advancements in artificial intelligence (AI) have spawned a fourth industrial revolution. According to the World Economic Forum, it's a time in history “that will fundamentally alter the way we live, work, and relate to one another. In its scale, scope, and complexity, the transformation will be unlike anything humankind has experienced before.” New developments in AI and automation in healthcare will offer numerous benefits to providers. The impact of recent technology advancements in healthcare is staggering. New AI and automation tools can detect human illnesses faster, monitor patients in the privacy of their homes, and streamline laborious administrative healthcare workflows to save providers up to $360 billion annually. The impact of AI and automation in healthcare is just beginning. Here are three ways these tools can help prevent and reduce claim denials, alleviate staff workloads and improve the patient experience. 1. AI and automation helps lessen claims errors Experian Health's State of Claims Survey 2022 reported that 61% of providers rely too heavily on manual processes and lack the automation necessary to streamline reimbursement. Billions of dollars are tied up in rejected claims; healthcare professionals say up to 15% of their claims are denied. However, many denials are preventable simply by eliminating human error stemming from manual workflows. When paperwork is still done by hand, mistakes in eligibility verification or incorrect insurance information are all too common. Some of the typical reasons for claims denials include data entry errors. Claims are complex, and providers handle most revenue cycle tasks manually, so it's common for incorrect insurance details, eligibility verification problems, or other inaccurate or missing information to make it through to claims submission. Far from being science fiction, the newest AI-powered administrative tools can scan patient claims data to detect errors that lead to denials. Given that diagnostic errors alone cost more than $100 billion and affect 12 million Americans annually, this new breed of AI tools offers providers a way to improve care delivery while lessening the endless hassle of claims denials. AI and automation tools can help eliminate up to errors that lead to denied claims. For example: Patient Access Curator automates insurance eligibility and coverage, scanning patient documentation for inaccurate information. The software uses AI and robotic process automation (RPA) to reduce manual errors. AI Advantage™ works to prevent denials before they happen: AI Advantage -Predictive Denials spots claim errors before submission to the payer. It's an early warning system designed to reduce denials by red flagging claims errors. But it also flags claims that fail to meet payer requirements—even if those requirements have recently changed. 2. AI and automation reduces manual processes and staff burnout Manual processes in healthcare contribute significantly to burnout, which affects nearly 50% of staff. The cost of staff burnout and preventable turnover runs around $4.6 billion annually. However, overworked staff leads to mistakes in manual processes and ultimately claim denials, so the cost of burnout directly affects the revenue cycle.Experian Health's 2023 staffing survey shows 100% of healthcare providers say staffing shortages have impacted their revenue cycle. But staff burnout and turnover affect more than reimbursement—more than 80% say it also negatively impacts the patient experience. AI and automation in healthcare can help alleviate the overwork that many staffers feel. Experian Health offers solutions to automate manual tasks, free up staff time, and reduce the volume of claims denials. ClaimSource® reduces the industry's average claims denial rate of 10% or higher to 4% or less. This software automatically scans claims, payer compliance, insurance eligibility, and patient demographics to spot the errors that lead to denials. Automating claims submission lessens the administrative burden and improves the work/life balance for overburdened staff. AI Advantage - Denial Triage covers any claims that end up rejected, prioritizing claims with the highest rate of ROI for providers. The solution uses artificial intelligence to help staff organize their efforts toward the highest revenue generating opportunities to increase revenue collection. It can lessen workloads and help teams work smarter for a higher return and better bottom line. 3. AI and automation in healthcare improves patient experiences Automation improves the patient journey. Experian Health and PYMNTS research show positive patient experience starts with self-service scheduling and registration. This kind of digital front door puts control back in the hands of patients, who are frustrated by time-consuming administrative processes. Patients have high expectations for better tech experiences throughout their healthcare encounters. Experian Health offers solutions that give customers exactly what they demand. For example: Patient Scheduling software allows 24/7 online access to appointment setting tools. In addition to making a more convenient and accessible scheduling process, this tool reduces the time it takes to set an appointment by 50%. The benefits for healthcare providers include a higher patient show rate (89% on average) and higher patient volumes (32% more patients per month). Patient Financial Advisor offers seamless, automated service estimates that go straight to the patient's favorite digital device. The tool creates a transparent payment process to help patients understand their treatment's cost and payment options. Patient Financial Advisor integrates with a secure online payment portal. These tools establish financial accountability up front while eliminating unnecessary surprises that affect the provider/patient relationship. Benefits of AI and automation in healthcare AI and automation in healthcare are changing how patients experience care delivery, how providers interact with their customers, and how clinicians manage getting paid. The benefits of using these tools include: Faster and more accurate patient diagnoses. Fewer patient readmissions and more proactive care management. Streamlined administrative tasks to reduce claims denials and improve the revenue cycle. Experian Health offers a suite of technology solutions, including a revenue cycle data curator package, to help providers get paid faster, free up staff time, and improve the patient experience. These solutions can help healthcare organizations achieve their goals by harnessing the latest AI and automation technologies to work smarter. Connect with an Experian Health expert today.
There is growing concern that the healthcare industry needs more clinical and administrative staff to handle care demands. The crisis affects patients beyond treatment delays or lower care quality. Staff shortages in the revenue cycle create problems with patient engagement, billing, and collections. A recent Experian Health survey reveals unanimous concerns among providers about the challenges posed by workforce shortages. But what are the root causes of staffing shortages in healthcare? Is there a remedy for healthcare organizations struggling to find the talent they need? This article dives into the survey findings and the ways healthcare providers can address staffing shortages effectively. Finding 1: Staff turnover is a significant cause of healthcare staffing shortages. 80% of providers report turnover between 11-40%. Nearly one in 10 say turnover is between 41-60%. The causes of staff shortages were evident before COVID. A rapidly aging Baby Boomer population and limited availability of training in areas such as nursing led to predictions that looming staff shortages were on the horizon. The pandemic exacerbated the situation, leading to a mass exodus of workers and The Great Resignation. Some reports show healthcare lost 20% of its workforce, including 30% of nurses. Today, the average hospital turns over one-quarter of its staff annually, an increase of more than 6% from the prior year. As a result, the State of Patient Access 2023 reported nearly 50% of providers say access to care is worsening. Simultaneously, healthcare is bogged down with administrative tasks. Increasing evidence shows providers must turn to automation software to decrease human workloads and stretch small teams further. These automated tools can: Create a seamless registration process for patients to improve care access, reduce no-shows, and reduce provider administrative burdens. Provide 24/7 patient scheduling and put patients in charge with self-scheduling options Automate patient outreach to increase collections and improve communication. Improve claims management, reduce denials, and free up existing staff from manual tasks. Automation can improve the work-life balance of healthcare staff, potentially closing the revolving turnover door, one of the most significant causes of staff shortages. For example, IU Health implemented automated guided scheduling, which helped scale their operations, reduce scheduling errors and improve staff efficiency. Finding 2: Finding and hiring staff is an undue burden for healthcare providers. 73% of respondents said finding qualified staff is difficult. 61% reported that meeting entry-level staff's salary expectations is a challenge. Healthcare organizations feel the staffing crisis at every level. A recent Medical Group Management Association (MGMA) poll cited the difficulties in hiring revenue cycle staff: 34% of respondents stated hiring medical coders is their biggest challenge. 26% stated billers were difficult to find. One-third said finding schedulers and prior authorization staff is hard. Other hiring challenges included revenue cycle management (RCM) managers. When and if healthcare providers find staff, bringing them into the fold is costly. Experian Health's staffing survey showed most organizations struggle to meet the salary expectations of even the least experienced members of their teams. The causes of staff shortages can be remedied by leveraging new artificial intelligence (AI)-powered tools. Tools like AI Advantage™ can automate and transform claim denials management, a problem costing healthcare providers around $250 billion annually. Experian Health's State of Claims 2022 survey showed the most common causes of denied claims include: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Inaccurate medical coding. AI Advantage reduces denial rates by scrubbing claims and flagging errors before submission. After claim submission, the software prioritizes the most high-value denials for correction to maximize revenue generation. Organizations like Schneck Medical Center use these tools to reduce denials by 4.6% each month. The facility also increased the speed of claims submissions. Tasks that used to take 12 to 15 minutes to rework now process in less than five minutes, lessening the need for hiring more staff and improving the workloads of their existing team. Finding 3: Burnout is a top contributor to staffing shortages. 53% of poll respondents said staff burnout is a key cause of the current staff shortage. 48% said the new expectation for schedule flexibility and hybrid work models also contributes to the healthcare workforce shortage. Burnout is one of the most significant causes of staff shortages impeding high quality care and wreaking havoc on the revenue cycle. The latest data shows the percentages of clinical and administrative burnout in healthcare is approaching or exceeding 50% in most job categories: 56% of nurses report burnout symptoms. 54% of clinical staff. 47% of doctors. 46% of non-clinical staff. Cost-cutting and increasing care demands have led to increasing fatigue in healthcare staff. But technology exists to automate back office functions that could free up staff time. For example, organizations like Kootenai Health saved close to 60 hours of staff time in over 8 weeks by automating the presumptive charity process Patient Financial Clearance. Stanford Health used Collections Optimization Manager to cut 672 hours each month from overburdened back office staff. The COVID pandemic also changed expectations about how and where Americans should work. Remote work became normal; three years post-COVID, 58% of the American workforce report working remotely at least one day a week. The same data also shows that when workers have the chance to work virtually, 87% take it. Healthcare is not immune to the desire for more schedule flexibility. Becker's Hospital Review states, “Many workers desire the ability to work remotely, even if they only get the option a few days a week. Flexibility allows people to maintain work-life balance—and in a high-burnout field like healthcare, balance can be crucial.” Surveys show 31% of healthcare roles are remote full-time while 14% offer this flexibility part-time. The problem is that many healthcare positions cannot allow this flexibility—and the industry competes with others that do. To remain competitive, healthcare organizations must embrace technology to offer work flexibility. Cloud-based digital technology is beneficial in areas like the revenue cycle. For example, automated technology from Experian Health can: Use advanced analytics to streamline workflows. Facilitate patient self-service. Minimize staff time spent on manual tasks. AI-powered automation tools can lessen staff burnout by allowing them to work smarter. These tools provide the workforce with the scheduling flexibility they desire. Eliminate the causes of healthcare staffing shortages with better technology AI and automation technology in healthcare can lessen worker fatigue, lighten workloads, and give administrative workers the schedule flexibility they demand. Experian Health offers healthcare providers better technology to improve the lives of their staff, increase patient satisfaction, and generate more revenue. Download the survey or connect with an Experian Health expert today to learn how we can help your organization tackle the causes of healthcare staffing shortages effectively.