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

Like many other sectors, healthcare providers are increasingly turning to automation and artificial intelligence (AI) to get more accurate data and better insights. However, the pace of change is somewhat slower in healthcare, due to legacy data management systems and data silos. As efforts to improve interoperability progress, providers will have more opportunities to deploy AI-based technology in innovative ways. This is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for AI to help maximize reimbursements. This article looks how AI and automation can help providers address the problem of growing denials, and how Experian Health's new solution, AI Advantage™, is helping one particular provider use AI to reduce claim denials. Using AI and automation to address the claims challenge Experian Health's 2022 State of Claims survey revealed that reducing denials was a top priority for almost three quarters of healthcare leaders. Why? High patient volumes mean there are more claims to process. Changing payer policies and a changing payer mix layer on complexity. Labor shortages mean fewer hands on deck to deal with the workload, while rising costs and tighter margins mean the stakes are higher than ever. Manual claims management tools simply cannot keep up, resulting in lost time and revenue. Automation and AI can ease the pressure by processing more claims in less time. They give providers better insights into their claims and denial data, so they can make evidence-based operational improvements. AI tools achieve this by using machine learning and natural language processing (NLP) to identify and learn from patterns in data, and synthesizing huge swathes of data to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation can be used to complete rules-based, repetitive tasks with greater speed and reliability than a person might be able to achieve. Discovering new use cases for AI in claims management Providers are finding new applications for AI as utilization becomes more widespread. Some examples of different use cases include: Automating claims processing to alleviate staffing shortages: AI tools can use natural language processing (NLP) to extract data from medical records and verify accuracy before adding the information to claims forms. This saves staff significant amounts of time and effort. Augmenting staff capacity and creating an efficient working environment can also help with recruitment and retention. Reviewing documentation to reduce coding errors: AI can perform the role of a “virtual coder,” using robotic process automation and machine learning to sift through medical data and suggest the most appropriate codes before claims are submitted. Using predictive analytics to increase operational efficiency: One of the most effective ways to improve claims management is to review and learn from past performance. AI can analyze patterns in historical claims data to predict future volumes and costs, so providers can plan accordingly without simply guessing at what's to come. Improving patient and payer communications with AI-driven bots: The claims process requires large amounts of data to be exchanged between providers, payers and patients. AI-driven bots can be used to take care of much of this, for example by automatically responding to payers' requests for information during medical necessity reviews, or handling basic inquiries from patients. Case study: How Community Medical Centers uses AI Advantage to predict and prevent claims denials Community Medical Centers (CMC), a non-profit health system in California, uses Experian Health's new solution, AI Advantage, which uses AI to prevent and reduce claim denials. Eric Eckhart, Director of Patient Financial Services, says they became early adopters to help staff keep up with the increasing rate of denials, which could no longer be managed through overtime alone. “We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with the results we're seeing now.” AI Advantage reviews claims before they are submitted and alerts staff to any that are likely to be denied, based on patterns in the organization's historical payment data and previous payer adjudication decisions. CMC finds this particularly useful for addressing two of the most common types of denials: those denied due to lack of prior authorization, and those denied because the service is not covered. Billers need up-to-date knowledge of which services will and will not be covered, which is challenging with high staff turnovers. AI Advantage eases the pressure by automatically detecting changes in the way payers handle claims and flagging those at risk of denial, so staff can intervene. This reduces the number of denials while facilitating more efficient use of staff time. Eckhart says that within six months of using AI Advantage, they saw 'missing prior authorization' denials decrease by 22% and 'service not covered' denials decrease by 18%, without any additional hires. Overall, he estimates that AI Advantage has helped his team save more than 30 hours a month in collector time: “Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in house and save money. The savings have snowballed. That's really been the biggest financial impact.” Hear Eric Eckhart of Community Medical Centers and Skylar Earley of Schneck Medical Center discuss how AI Advantage improved their claims management workflows. AI AdvantageTM: two steps to reducing claim denials AI Advantage works in two stages. Part one is Predictive Denials, which uses machine learning to look for patterns in payer adjudications and identify undocumented rules that could result in new denials. As demonstrated by CMC, this helps providers prevent denials before they occur. Part two is Denial Triage, which comes into play when a claim has been denied. This component uses advanced algorithms to identify and segment denials based on their potential value, so staff can focus on reworking the denials that will make the biggest impact to their bottom line. At CMC, denials teams had previously focused on high value claims first, but found that smaller payers sometimes made erroneous denials that could add up over time. AI Advantage helped root these out so Eckhart's team could resolve the issue with payers. Integrated workflows reveal new applications for AI and automation AI Advantage works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. In this way, AI Advantage fits into the same workflow as tools that providers may already be using, such as Claim Scrubber, Enhanced Claim Status and Denials Workflow Manager. These integrations amplify the benefits of each individual tool, giving healthcare providers better insights into their claims and denials data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Discover how AI Advantage, Experian Health's new claims management solution, can help providers use AI to reduce claim denials.

As 2023 draws to a close, revenue cycle leaders are in planning mode, reviewing financial performance, and gearing up for resource allocation negotiations in the new year. What should they be prioritizing? Three of Experian Health's senior executives share their healthcare predictions for 2024 based on the latest healthcare trends, and the steps providers can take to maximize reimbursements in the year ahead. Healthcare prediction #1: “Staffing shortages will persist, driving demand for technology-based solutions over traditional HR tactics” According to Jason Considine, Chief Commercial Officer, the healthcare staffing shortage is unlikely to let up any time soon: “In our recent survey, we found that 100% of respondents are seeing ongoing shortages affect revenue cycle management and patient engagement. There's an urgent need to address the problem, but too many providers are relying on traditional recruitment approaches that won't give them the longer-term resilience they need. Heading into 2024, providers should leverage technology and data to alleviate the burdens on front and back-end operations, and drastically improve efficiencies. This will better protect providers from the talent pipeline fluctuations that cause major disruptions.” This healthcare prediction for 2024 is based on Experian Health's staffing survey that was relased in 2023. Participants in the survey agreed that the staffing crisis would continue, expressing concerns about its impact on revenue and patient engagement. For many, the culprit is high turnover rates. More than four in ten said turnover in their administrative teams exceeds 25%. Given the difficulties in finding skilled candidates and addressing staff burnout, it seems clear that traditional HR-based strategies will fall short. Despite this, salary increases, cross-training and incentives remain go-to responses. Responding to the survey findings, Considine says, “It's time to look at the many areas where automation – and even artificial intelligence – can stabilize, improve and optimize understaffed functions.” One use case for artificial intelligence is in claims management. Experian Health's AI Advantage™ solution uses historical and real-time claims data to identify claims that may be at risk of being denied. This allows staff to zero in on those claims and ensure all information is correct and complete before submission. It integrates seamlessly with ClaimSource® to augment the claims workflow, so staff can focus on claims and denials with the highest likelihood of payment. As well as alleviating pressure on staff, it reduces costs and maximizes reimbursements, helping providers to protect margins during uncertain times. See how AI Advantage helps healthcare organizations reduce and prevent claims denials. Prediction 2: “Patients' changing digital expectations will prompt more providers to adapt (and those that don't will risk losing market share)” Clarissa Riggins, Chief Product Officer, says that patients are increasingly likely to expect a better “digital front door” experience, and will start to look elsewhere care if they encounter too much friction: “Patients have increasingly high expectations for easy and efficient tech-enabled solutions when it comes to accessing healthcare services. They seek convenient self-scheduling options, accurate cost estimates, and the ability to pre-register through their smartphones. We're seeing a continuing trend in the number of patients who say they'd switch providers if the digital front door isn't open.” That healthcare trend was evident in Experian Health's State of Patient Access 2023 survey, which showed that 56% of patients who had seen a deterioration in the patient access experience would switch providers because of it. Demand for more digital options can be tracked back to the “Amazon effect” and the rise of online retail environments that give consumers convenience and choice at the tap of a button. Indeed, healthcare providers stepped up during the pandemic to deliver flexible, contactless care, so patients have seen that it's possible. With digital transactions now well-established, patients will find it surprising to be asked to fill out paper forms at the registration desk or have limited online payment options in 2024. Riggins says providers must update their technology or risk being left behind. “Clients who are making the switch to digital patient access offerings tell us they don't want to look stuck in the 90s. They want a more contemporary patient experience that's smoother and more efficient for both patients and staff.” To open the digital front door and kepe up with healthcare predictions in 2024, Riggins recommends prioritizing self-service and digital options for patient registration, scheduling and billing inquiries. Prediction #3: “More patients are struggling financially, so providers will need to do more – and sooner – to help them manage bills” Victoria Dames, Vice President of Product Management, says that with household finances under pressure, patients will remain anxious about the cost of care: “The earlier providers can give patients clarity, the better for all involved. Creating a convenient and transparent patient collections experience should begin during patient onboarding, so patients can start to plan. With integrated patient access software, providers can deliver a more compassionate and efficient collections process, which supports patients while accelerating the revenue cycle. They don't have to choose between prioritizing revenue and patient experience – patient access technology delivers on both.” Recent Experian data suggests that many Americans are not confident in their financial literacy. This does not bode well for their ability to navigate the increasingly complex processes involved in healthcare billing. The troubling health consequences are already evident: a 2023 Gallup poll revealed that record numbers of patients were putting off medical care because they were worried about the cost. Anything providers can do to simplify the payment process is going to improve access to care and minimize bad debt, as noted in Dames' healthcare predictions for 2024. Dames says the collections effort should be viewed as an ongoing interaction with patients, beginning in patient access: “Patient access is where providers begin collecting data, confirming insurance eligibility, and providing accurate patient estimates. Completing these actions successfully at the beginning of the patient journey, with compassionate and frictionless patient interactions, can facilitate payment and collections downstream.” A better financial experience in 2024 should include self-service and digital tools that guide patients through each step of their financial journey. For example, PatientSimple® gives patients a user-friendly, comprehensive way to generate price estimates, apply for charity care, set up payments plans and even make payments, all through a single web-based portal. Patient Payment Estimates deliver accurate pre-service cost estimates through the patient's preferred channels and point them toward any appropriate financial assistance. And of course, offering a wide range of convenient and flexible payment options will promote timely payments and maximize collections. Learn more about our revenue cycle management solutions or contact Experian Health today to discuss how we can support your strategies, based on our healthcare predictions for 2024.

100% isn't always a good thing. That's especially the case when 100% of healthcare providers agree that staffing shortages have impacted their revenue cycle management and patient engagement efforts. The pressure is on, especially as providers start to see the financial consequences impact their bottom lines. Experian Health's latest report, Short-staffed for the long term, takes a deeper-dive into the many ways staffing shortages have impacted healthcare providers and their organizations. This report, released in November 2023, surveyed 200 healthcare employees responsible for staffing the revenue cycle function. It takes a look at the causes of staffing shortages, the impact on different revenue cycle areas, and the ways technology can help. Take a look at some of the healthcare staffing shortage stats: Download the report, Short-staffed for the long term, or contact us to see how Experian Health can help your organization find some relief from staffing shortages.

“We wanted the right technology that could look for insurance coverage for self-pay patients without the need for us to increase our manpower. The cost savings were a big win for the department.” — Brent Rikhoff, Director of Pre-Access, UCHealth Challenge UCHealth is an integrated health system with a network of 12 hospitals and more than 30,000 employees. At the height of the COVID-19 pandemic, UCHealth maintained its commitment to an excellent patient experience by giving all patients access to tests and vaccinations. Costs for uninsured and self-pay patients could be recovered under the Health Resources and Services Administration's (HRSA) COVID-19 Uninsured Program (UIP), but only after confirming that the patient had no relevant active coverage. If they missed this step, UCHealth would be landed with bad debt, increasing collection costs and unwanted audits: they needed a reliable way to track and verify insurance coverage accurately and in real-time. Solution UCHealth chose to use Coverage Discovery® after experiencing positive results with Experian Health's Eligibility solution. Coverage Discovery allowed them to scan the entire revenue cycle for billable commercial and government coverage that patients may have been unaware of or forgotten about. The tool gave UCHealth access to Experian's proprietary databases, including employer group mapping and patient search history, so they could track and verify potential coverage in multiple locations. This made it much easier to find insurance information for plans without a self-pay search feature. After seeing positive results, UCHealth expanded their use of Coverage Discovery to self-pay and emergency department patients. This helped them root out discrepancies in patient accounts and prevent accounts from being misclassified as bad debt or charity. Uncovering additional active coverage was also a major benefit for patients. Discover the top 4 strategies to optimize patient collections while delivering a more compassionate financial experience for patients. Outcome Thanks to Coverage Discovery, UCHealth achieved the following results: Over $62 million in insurance payments in 2022, a 25% increase from 2021, includes payments from their top three payers $45 million in coverage found between May 2022 and May 2023 Over $3.5 million in collection costs savings in 2022 Overall, Coverage Discovery has helped UCHealth create a more streamlined approach to verification and billing. The batching feature made it easy for staff to process the backlog of patient accounts awaiting insurance verification, while access to large, current datasets facilitated more accurate billing. Director of Pre-Access at UCHealth, Brent Rikhoff, said the ability to integrate Coverage Discovery with Epic® enabled the team to achieve proper reimbursement for services rendered. Expanding the solution to include Medicaid coverage identification would be an obvious next step for UCHealth, following this impressive return on investment. Learn more about how Coverage Discovery identifies missing and forgotten billable coverage, so healthcare providers can get fully reimbursed while maintaining an outstanding patient experience.

The media has extensively covered the healthcare workforce shortage and its impact on patient care. It's a chronic, dangerous problem that seems to worsen, despite the industry's efforts to staff up. A recent Experian Health survey found severe and long-term implications for revenue cycle management and its impact on provider and patient care. 100% of revenue cycle leaders surveyed agree the pervasive healthcare workforce shortage impacts their facility's ability to get paid. The problem isn't going away; most survey participants (69%) expect recruiting challenges to continue. Furthermore, nine of 10 survey participants admit to a double-digit turnover rate. However, the shortage of qualified labor is impacting healthcare in other areas beyond patient outcomes. The report shows the bottom line is clear: The healthcare workforce shortage impedes the industry's ability to get paid. How can providers solve this? Experian Health's survey, “Short Staffed for the Long-Term,” polled 200 revenue cycle executives to understand the impact of the hiring deficit's impact on provider cash flow. Survey Finding #1: Staffing shortages impede payer reimbursements and patient collections. 32% of survey participants said patient collections is the revenue cycle channel most impacted by healthcare workforce shortage. 22% said payer reimbursements are most affected by staff shortages. 43% said both channels were equally impactful to the healthcare revenue cycle. There was little disagreement in the survey around whether provider revenue cycle suffers from a lack of qualified staff. The debate centered on which reimbursement channel took the biggest hit. Experian Health's staffing survey revealed revenue cycle executives agree that collecting late patient payments is much more complicated now. The worker shortage impedes the ability to manage this process. In an era when many patients put off care due to high out-of-pocket costs, maximizing collections is more important than ever. Short-staffed, overworked healthcare collections teams require the time and tools to optimize the collections process by identifying the accounts more likely to pay. Patient collections teams could also benefit from software that finds financial assistance that could ease self-pay burdens. Collections Optimization Manager saves staff time by automatically determining the most suitable patient collections approach. The University of San Diego California Health (UCSDH) uses this software to segment patients by propensity to pay. It allows collections agents a more efficient, personalized approach to improve the revenue cycle and the patient relationship. From 2019 to 2021, UCSDH increased collections from $6 million to more than $21 million with this solution. Patient Financial Clearance automates screening prior to service or at the point of-service to determine if patients qualify for financial assistance, Medicaid, or other assistance programs. Kootenai Health leverages the software, which increased the accuracy of determining patient financial assistance by 88%, and saved 60 hours of staff time through automation. Together, these tools can ease the healthcare workforce shortage by optimizing and streamlining collections. Survey Finding #2: The healthcare workforce shortage contributes to increasing denial rates. 70% say escalating staff shortages increase claims denials. 92% report new staff member errors are a significant factor in delayed or declined reimbursement. Today, healthcare providers are seeing claim denials increase by 10 to 15% year over year. A lack of qualified revenue cycle staff costs billions annually in preventable revenue cycle errors. 35% of healthcare leaders admit losing more than $50 million yearly on denied claims. The complexities of the revenue cycle particularly challenge new staff; 92% of survey respondents say errors are common. Denied claims ripple across the revenue cycle, tying up staff time and provider cash flow. Ultimately, it is patients and staff who suffer. When hospitals experience restricted cash flow, it can hamper their ability to effectively deliver the highest quality care. When staff stretch to their limit due to the healthcare workforce shortage, they may make more errors, burnout, or quit. Automating the claims process is a necessity in this challenging environment. Tools like ClaimSource® and Claim Scrubber can catch errors before submission, reducing undercharges and denials. Franklin Healthcare Associates, a 100-provider, four-location practice, used Claim Scrubber to reduce accounts receivable (A/R) by 13%. As claims volume grew, the practice decreases its full-time employee (FTE) requirements by leveraging this automated tool. It's one clear example of how technology can stretch staff farther to improve the bottom line. Survey Finding #3 Staffing deficits aren't going away. Close to 70% of respondents believe revenue cycle staffing levels will continue as a problem into the future. Staff turnover is a contributing factor; 80% said their organization's turnover revenue of cycle management staff is between 11-40%. Experian Health's survey confirms that healthcare teams struggle to find qualified staff. Staff turnover is a significant contributor to a revolving hiring door. One survey showed the average hospital turnover rate is 100% every five years. Traditional solutions to the problem include throwing more money into salaries, bonuses, or other perks. Overtime is a go-to remedy for the chronic healthcare worker shortage. But these approaches strain the provider bottom line. A recent Kauffman Hall survey shows: 98% of healthcare providers have raised minimum wage or starting salaries. 84% offer signing bonuses, and 73% offer retention bonuses. 67% experienced wage increases of more than 10% for clinical staff. The American Hospital Association (AHA) states, “Hospitals also have incurred significant costs in recruiting and retaining staff, which have included overtime pay, bonus pay and other incentives.” But what if recruiting isn't the answer to the healthcare workforce shortage at all? Artificial intelligence (AI) and automation software can help cut costs and lessen the workload of existing staff. The latest data suggest providers could save close to $25 billion annually (one-half of what they spend on administrative tasks) if they leveraged these tools. Experian Health's  AI Advantage™ uses powerful algorithms to automate manual claims processes to reduce denial and lessen the volume of tasks for revenue cycle staff. The software works in two critical areas: Predictive Denials proactively cleans claims before they are submitted. The software flags claims at risk of denial, allowing manual intervention for a clean submission—with no denials. Denial Triage manages denied claims by identifying the highest value reimbursements to maximize cash flow. Instead of chasing low-value claims or those least likely to pay, the software prioritizes where revenue cycle staff should spend their time for the greatest return. Schneck Medical Center saw significant ROI from this software in just six months. AI Advantage helped the facility reduce denials by an average of 4.6% per month. Claims corrections that took up to 15 minutes in the past now take under five minutes. Better software can do more than help hospitals get paid faster. Automating revenue cycle management processes frees up staff time. More time and less pressure mean fewer mistakes. Automation can ease the impact of the healthcare workforce shortage Two of the most pressing problems hospitals face today are the healthcare workforce shortage and revenue cycle impediments that keep them from getting paid. These challenges interconnect, and providers can solve them both with better technology to automate time-wasting manual functions. AI and automation in healthcare can cut costs and reduce staff burnout. Deploying revenue cycle software to automate billing, claims management, and collections could save $200 billion to $360 billion in spending in this country. These numbers are real. But so are the numbers showing increasing claims denials, staff burnout, turnover, and difficulties recruiting in the healthcare field. Today, the answer for hospitals to get paid faster is to leverage modern technology to improve the revenue cycle. Learn more about how Experian Health's revenue cycle management solutions can help automate common processes, and download the new survey to see the latest healthcare staffing shortage stats.

Could common revenue cycle management (RCM) myths be preventing healthcare organizations from getting paid in full? Does what constituted best practice a few years back still apply to revenue cycle operations today? Many providers are embracing new technology to strengthen their RCM processes, using automations and software to create more accurate and efficient billing and claims management workflows. But if these processes are built on shaky assumptions, the results will be sub-optimal. As year-end financial reviews get under way, there is a prime opportunity to re-evaluate some long-standing beliefs about billing, collections and payments that, if not set straight, could limit financial performance in the year ahead. This article examines four of the most common revenue cycle myths and considers what providers can do to make financial growth a reality in 2024. Revenue Cycle Myth 1: All patients are equally likely to pay Reality: No two patients are alike – whether in their medical needs or financial circumstances. Providers know this, yet many rely on revenue cycle management solutions that lean toward a one-size-fits-all approach to patient payments. Instead, providers should consider RCM tools that use data and analytics to segment patients according to their individual financial situation, to create a more personalized and proactive approach to collections. This should take account of both the patient's ability to pay (i.e., whether they can afford their bills), and their likelihood to pay promptly, which may be enhanced by offering payment options that are convenient and aligned to their personal preferences. Collections Optimization Manager analyzes patients' individual payment history and demographic information so their accounts can be routed to the most appropriate collections pathway from the start. Patients that are likely to pay quickly can be sent billing information automatically and presented with self-service payment options. Alongside this, Patient Financial Clearance pulls together credit and non-credit data to help providers identify patients who may need a little more guidance and connect them to suitable payment plans. It catches any individuals who may be eligible for Medicaid or charity support. Staff get accurate, at-a-glance data to help them have sensitive financial conversations with patients, and can avoid losing time chasing collections from patients who would never have been able to pay. Case study: See how Stanford Health Care improved collections with a tailored, patient-focused approach to healthcare collections. Myth 2: It's hard to have meaningful pre-service financial conversations with patients Reality: Contrary to popular belief, most patients are receptive, and even eager, to have financial discussions with their provider as soon as possible. Doing so need not be challenging. In the past, providers may have worried that broaching the money question could deter patients from seeking necessary care, or simply not prioritized such discussions. Billing and insurance can also be highly complex, which may lead staff to assume that patients would find conversations about these issues to be confusing or overwhelming. But it is for these exact reasons that providers should have financial discussions with patients as early as possible. Experian Health's 2023 State of Patient Access survey found that almost 90% of patients wanted upfront pricing estimates so they could plan ahead for their financial obligations – yet less than a third received one. Tools like Patient Payment Estimates and Patient Financial Advisor can calculate cost estimates, taking account of the patient's claim history, deductibles and other insurance information, and automatically send these to patients before treatment so they know what to expect. These can also be combined with quick payment links so bills can be cleared before care. Giving patients consistent information through whichever digital channel they prefer means they will be better positioned to make informed decisions and discuss their situation with patient access staff if necessary. When patients are better informed and supported, they're also less likely to end up postponing care due to cost concerns. And with the same accurate data at their fingertips, patient access staff can serve as financial concierges, helping patients to understand coverage and copayments and check eligibility for relevant financial assistance programs. In addition to user-friendly data tools, providers should consider whether staff would benefit from additional training to bolster their confidence in leading compassionate financial conversations. Myth 3: It's impossible to know what patients owe across a system with a single look-up Reality: Thanks to data analytics and digital payment technology, it is now pretty straightforward to consolidate a patient's outstanding balance information from across an entire health system, and debunks common revenue cycle myths. Patient access staff can view a comprehensive summary of a patient's insurance status, estimated liability and open balances from multiple providers, enabling them to have meaningful financial conversations with patients. Even if these discussions do not lead to immediate payment, they can still act as a reminder to nudge the patient to act soon, thus accelerating the payment process. Selecting RCM tools from a single vendor makes it easier to integrate data from multiple workflows and generate a unified view of what a patient owes. When systems talk to each other, it's possible for a single tool to leverage the data and create a better experience for patients and staff. For example, PaymentSafe® automatically brings together data gathered throughout the revenue cycle to streamline what was previously a disjointed and time-consuming process. With point-to-point encryption, it accepts secure payments at any point in the patient's journey, using cash, check, card payments and recurring billing, through a single web-based application. Myth 4: Revenue cycle management is “set-and-forget” Reality: Revenue cycle managers may dream of setting up a system once and then forgetting about it, but the reality is that managing billing, claims and collections is an ongoing and evolving process that needs constant attention. Healthcare organizations must regularly review and adjust their RCM strategies to prevent missed revenue opportunities, manage compliance risks and promote operational efficiencies. That said, data analytics and automated revenue cycle management tools do make it far easier for providers to stay on top of RCM demands. These tools help providers with everything from monitoring payer policy changes and identifying billing errors to personalizing patient communications and generating monitoring reports. Artificial intelligence takes it a step further, for example, by preventing and predicting claim denials. In this way, these tools reduce the need for extensive staff input, so staff can spend more time focusing on the issues that need more human attention. With up-to-the-minute reports covering multiple RCM processes, staff also have the information they need to optimize performance and find opportunities to boost reimbursement that may have been previously overlooked. So, while RCM is not quite a “set-and-forget” process, automations and analytics can simplify it significantly, so it's less labor-intensive for staff and more efficient overall. Debunk revenue cycle myths and proactively challenge assumptions to increase profitability Debunking these revenue cycle myths is simple and achievable with tools that integrate a patient's clinical and financial data for a fuller picture of what that patient needs. This is crucial as changing consumer expectations, economic drivers, and new technology reshape how patients, providers and payers interact with one another. Checking underlying assumptions in any RCM process is essential to root out potential misunderstandings and outdated thinking. Not doing so leaves providers vulnerable to inaccurate financial projections, mismatched strategies and poor patient experiences. See how Experian Health's industry-leading Revenue Cycle Management Solutions make streamlined billing and collections a reality.

Prior authorizations ensure that patients only receive care that is medically necessary, evidence-based and cost-effective. The process is a built-in safety net to prevent over-prescription of drugs and services, avoid duplication of tests, and make sure that ongoing treatments are actually helping the patient. At least, that's the goal. Many providers and patients tell a different story. Too often these well-intentioned mechanisms morph into paper-based barriers to care that do more harm than good in the long term. According to the American Medical Association (AMA), nine out of ten physicians have seen prior authorizations have a negative impact on patient outcomes, while a third have seen authorizations lead to a serious adverse medical event. A major part of the problem is the growing administrative burden. Processing submissions manually is time-consuming and error-prone – and even more challenging in the context of staffing shortages. Automated prior authorizations can alleviate the pressure and help providers deliver care to the highest possible standards. How prior authorizations can obstruct patient access and treatment Health insurers demand that providers seek prior authorization for certain treatments and procedures before they will agree to cover the costs under the patient's plan. If the request does not meet the payer's specific rules and criteria, authorization will not be given, and financial responsibility will fall to the patient. If the patient can't pay, the unsettled sums will find their place in the accounts receivable ledger, eventually written off as bad debt. To avoid this scenario, patients and providers may decide against the proposed care plan. Findings in the AMA survey suggest that eight out of ten physicians had seen patients abandon treatment because of prior authorizations. Even where pre-authorizations are eventually approved, the lengthy administrative process to determine whether services and providers are covered can still delay treatment. Such delays cause the patient's medical situation to worsen, entailing more invasive and costly treatment later. This overutilization of services is clearly at odds with the stated purpose of prior authorizations and the 'triple aim' in healthcare. Manual prior authorizations exacerbate delays in patient care The problem is compounded by the fact that many providers rely on manual processes to manage prior authorizations. But with payer policies changing all the time, it's hard for providers to keep up and ensure submissions are accurate. Some procedures need to be approved under one health plan, but not under another, so it's easy for some to slip through unapproved and wreak havoc later. This is especially worrying for patients with more complex and chronic conditions, who require multiple services from multiple providers. Paper-based processes can be painfully slow, causing bottlenecks in patient care and errors that result in instant rejections when the submission is finally processed. There's an urgent need for a more efficient approach. Automated prior authorizations can reduce delays in patient care Recognizing the need for reform, in December 2022, the Centers for Medicare and Medicaid Services (CMS) proposed a new federal rule that would streamline the prior authorization process for Medicare Advantage plans, Medicaid and Children's Health Insurance Program managed care plans, and state and Marketplace coverage. If the rule comes into effect, it will require health plans to respond to urgent prior authorization requests within 72 hours, and to non-urgent requests within seven days. Affected payers would need to implement standardized interfaces and automations to improve data interoperability. Further information on this rule may is expected toward the end of 2023. Several states are making their own arrangements to regulate prior authorizations to help alleviate the administrative burden on providers, though these efforts have been described as a “mixed bag.” Ultimately, improving the prior authorization process comes down to making sure request documentation is filled out and submitted as accurately and as quickly as possible. The most effective way to do that is with the help of automated prior authorization software. Automated prior authorizations alleviate staffing challenges Providers are finding increasing value in prior authorization automations as they deal with ongoing staff shortages. In a staffing survey by Experian Health in August 2023, 37% of providers said their prior authorization processes were affected by staffing shortages. Neeraj Joshi, Director of Product Management at Experian Health, says that relying on manual processes in these circumstances is increasingly untenable: “For many providers, there simply aren't enough staff to manage the growing burden of prior authorizations. Remaining staff are stressed out, which unfortunately can lead to mistakes and bottlenecks. It creates a poor patient and staff experience. Automating prior authorizations eases the pressure by allowing more authorizations to be processed in less time and making it simpler for staff to track and follow-up inquiries. Not only does a faster approval process mean patients get care without delay, but it also reduces the risk of denied claims.” Read more about the key benefits of automating prior authorizations. How it works: key features of prior authorization software Experian Health's prior authorization solution, Authorizations, automates inquiries and submissions without user involvement. The software auto-fills payer data based on current requirements, guiding users to any tasks that need manual attention using an exceptions-based workflow. It proactively generates status updates so staff can see at a glance whether a request is pending, denied or authorized. These integrated automations increase operational efficiency by accelerating the authorizations process, minimizing unnecessary manual work, and reducing the risk of denials. Patients get the care they need, and providers get greater revenue cycle predictability. Overview of prior authorization platform features Authorizations accesses current prior authorization requirements in real-time using Knowledgebase, Experian Health's repository for national payer rules and criteria. Users can add local rules and updates as needed. Users are directed to the correct payer portal to make a submission for the procedure in question. Documents can be submitted to payers without electronic portals using integrated faxing. Automated inquiries give users an instant view of whether a submission is pending, denied or authorized. Dynamic work queues alert users to any tasks that need their attention. Authorization status, number and validity dates can automatically be posted back to health information and practice management systems. Images of payer responses can be stored securely using the integrated document imaging system. The software compares and reconciles authorized and delivered procedures. It flags any variances to staff can intervene to proactively prevent denials and appeals. Better communication will lead to better clinical outcomes Automations may not be able to resolve the conflicting perspectives of over-burdened providers and cost-conscious payers, but they can take the sting out of the administrative process. Prior authorization software smooths out the exchange of data so payers, providers and patients can communicate more effectively. With better communication, come better clinical outcomes – and that's in everyone's interests. A single-vendor solution extends this advantage internally, too. Integrating proven, cost-effective and compliant solutions with existing workflows can help front-end and back-office teams work together as efficiently possible. Experian Health's Authorizations solution integrates seamlessly with eCare NEXT®, leveraging automations in patient management and revenue cycle workflows, so providers can focus on their core competence: providing high-quality care to patients. Find out more about how Experian Health's automated prior authorizations help providers optimize patient care.

The complexities of healthcare claims management are a widespread, costly issue. While the American Medical Association (AMA) blames prior-authorizations as the main cause, it's clear that hospitals struggle to collect on predicted revenues often for months after they provide the service. It's not a sustainable situation as the costs of care delivery increase, staffing shortages drive up labor overhead, and inflationary pressures stretch healthcare providers to their breaking point. There is no question the claims denial process is ripe for innovation – and that's where artificial intelligence (AI) comes in. A 2022 Experian Health survey shows over one-half of healthcare providers increasingly turn to AI-driven healthcare claims management software to reduce claim denials. Tom Bonner, Principal Product Manager at Experian Health, says, “Adding AI in claims processing cuts denials significantly. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction – AI is the tool hospitals need for better healthcare claims denial prevention and management.” Common reasons for medical claim denials Revenue cycle leaders place healthcare claims management as their number one issue in 2023. Experian Health's survey showed the three most common reasons for medical claim denials were: Needs more data and analytics to identify submission issues. Manual claims processing and a lack of automation. Insufficient training for staff. The sheer volume of changes to CPT codes is another issue affecting HCM or healthcare claims management. Experian Health identified more than 100,000 payer policy changes from March 2020 to March 2022. These shifts necessitate a never-ending cyclic need to train new staff, increase the risk of claim rejections, and slow down manual workflows in healthcare claims denials management. How can healthcare providers improve claims processing and overcome these challenges? Real-life ROI with AI in claims processing AI in claims processing solves these and other common revenue cycle problems. This technology is the innovation healthcare providers need to reduce denials and increase cash flow. AI can help at every point in the revenue cycle continuum, from improving the accuracy of payer data upfront to ensuring a clean claim and even targeting denials that yield the highest return. What real-life lessons does AI in claims management teach healthcare providers? Experian Health's new AI-powered solution includes AI Advantage™ - Predictive Denials and AI Advantage™ - Denial Triage, which is geared towards helping healthcare organizations reduce claim denials. Within six months of using AI Advantage, Schneck Medical Center reduced denials by an average of 4.6% each month. Claim corrections that formerly took up to 15 minutes to correct cut to just under five minutes. Even smaller ambulatory clinics like Summit Medical Group Oregon benefit from automating healthcare claims management. After implementing Experian Health's claims management software, the provider saw an immediate reduction in claims denials. Today, they boast a 92 percent clean primary claims rate. These results are typical across healthcare organizations that implement AI in claims processing. But what does the software do to clean up the complexities of claims management processing? How to avoid claim denials with AI In 2022, Experian Health surveyed 200 revenue cycle leaders around the country and identified technology shortfalls as a significant contributor to claims denials: 62% reported they lacked the data analytics to identify submission issues. 61% said manual processes and a lack of automation were significant problems. 33% suggested their healthcare claims management software was outdated or inadequate. Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software. The benefits of these tools lie in their ability to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can also assist in identifying inaccurate claims, improving 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. Tom Bonner says, “AI in claims processing maximizes the benefits of automation for better claims processing, better customer experiences, and a better bottom line for healthcare providers.” How does healthcare claims denial management software work to improve the revenue cycle? AI identifies and prioritizes high-value claims after denial AI in claims processing goes beyond automating process-driven manual tasks. It also removes the guesswork from healthcare claims management. For example, staff is often left guessing which denied claims are the low-hanging fruit that they should process first. Staff must decide which denied claims have a higher likelihood of reimbursement and a higher dollar value to maximize their efficiency. Why would healthcare providers leave these high-value/high-return claims to a manual “best guess” estimation process? Yet that is standard operating procedure in most hospitals. AI in claims processing identifies and prioritizes high-value claims automatically. Experian Health's AI Advantage - Denial Triage goes to work when a claim is denied by identifying and intelligently segmenting denials based on potential value so that staff focuses on resubmissions with the most significant bottom line impact. This intelligent segmentation removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials. But the front-end work AI software completes during healthcare claims management may be even more valuable. AI can prevent claims denials from occurring at all. AI proactively stops claim denials from occurring AI Advantage - Predictive Denials uses AI to identify undocumented payer adjudication rules that may result in new denials. It identifies claims with a high likelihood of denial based on an organization's historical payment data and allows them to intervene before claim submission. Experian Health also has other automated solutions that help facilitate claims management. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software also generates accurate adjudication reports within 24 to 72 hours to speed reimbursement. ClaimSource ranked #1 in Best in KLAS 2023, precisely for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. AI optimizes the claims process Another Experian Health solution, Enhanced Claim Status improves cash flow by responding early and accurately to denied transactions. This solution uses RPA to give healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim denied. Speeds up the denials process. Automates manual claims follow-ups. Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims. Denials Workflow Manager integrates with the Enhanced Claim Status module to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. How to reduce claim denials with AI and Experian Health There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex on its own, but human error plays a large part in missed opportunities and lost revenue. With AI in healthcare claims management, the revenue cycle streamlines and transforms. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI healthcare claims management software offers provider organizations a way to achieve these goals. Contact Experian Health today to reduce claim denials and improve your claims management process with AI Advantage.