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Artificial intelligence (AI) is cropping up everywhere. But it's about to make an even bigger splash by revolutionizing how providers handle HCM (healthcare claims management). In healthcare, the claims process is a real source of frustration. Thirty-five percent of healthcare providers say they lose more than $50 million annually in denied claims. That's a lot of money lost for healthcare providers after care is delivered to their patients. As industry costs rise, healthcare claims management becomes an unsustainable financial drain for providers, who have no choice but to push these costs back to the patients they're trying to serve. Using AI for claims management has numerous benefits – and with denied claims on the rise, healthcare providers will need to incorporate this technology or risk leaving millions on the table. AI Advantage™, Experian Health's innovative predictive analytics software, uses AI in claims processing to help providers expedite reimbursement and improve cash flow. This software takes the unsolvable Gordian Knot that is U.S. claims reimbursement and untangles it for faster reimbursement, better cash flow, and less wasted time. Understanding AI in Healthcare Claims Management The odds are stacked against providers before the patient ever visits their practice. One patient claim can go through 20 or more checkpoints before the payer approves reimbursement. Denied claims are much less likely to be paid, and 89% of hospitals say denial rates are rising. An Experian Health survey said the three most common reasons for medical claim denials include: Missing or incomplete prior authorizations Failure to verify provider eligibility Inaccurate medical coding Without question, healthcare claims denial management must include better training for staff to file claims without error. Providers need accurate patient data upfront, with standardized verification processes at each step in the process.However, healthcare providers can reduce or completely avoid many common reasons for medical claim denials by using AI in claims processing. AI claims management software provides “teachable moments” for staff by sharing claims management errors at the front-end of processing before submission and possible rejection by the payer. Tom Bonner, Principal Product Manager at Experian Health, says, “Healthcare providers everywhere ask themselves: How can we reduce claims denials? But we have the technology to go even further. By using AI in claims processing, providers can avoid claims denials altogether by proactively spotting and correcting the human errors that slow down reimbursement before the claim is submitted to the payer.” Top Benefit of Using AI in Claims Processing – Providers Avoid Claims Denials AI and automation are the one-two punch providers need to improve healthcare claims processing. Using AI healthcare claims management software helps organizations avoid claim denials far upstream — before it occurs. AI Advantage – Predictive Denials is a preventative tool that proactively stops bad claims before they turn into costly denials. This AI-driven healthcare claims management software works in two key ways: By proactively identifying undocumented payer adjudication rules potentially resulting in denials. By identifying claims with a high likelihood of denial based on an organization's historical payment data. Schneck Medical Center improved their claims management processing by using AI Advantage – Predictive Denials to first identify error-prone claims. When the automated system spots the probability of a denial, it triggers an alert that routes the claim to an investigative biller. The AI carefully scrubs the claim, checking coding errors, authorization status, insurance eligibility, and more. Once the agent resolves these errors, they can successfully submit the claim to the payer. Using AI in claims processing leads to improved accuracy and fewer rejections for better revenue cycle management. After leveraging these tools for six months, Schneck Medical Center reduced denials by 4.6% on average per month. Benefit #2 – Healthcare Claims Management Software Speeds Denials Mitigation But what if a claim makes it through to the payer and they deny it? Denial management is a tedious, time-consuming process that impedes cash flow. AI Advantage – Denial Triage uses advanced algorithms to segment denials based on their potential value, allowing billers to focus first on high-value claims to maximize the revenue cycle and quickly reduce the denials queue. AI in reimbursement processing increases the speed of healthcare claims management to help staff identify and target the claims that need attention as quickly as possible without wasting time on low-value denials. By using automation and AI, healthcare providers gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Benefit #3 – AI Software Automates Reimbursement for Faster Payment Experian Health offers a streamlined series of standardized, automated tools to help with claims management. From registration, quality assurance, and eligibility on the front-end to claims processing and denials management on the back-end, Experian Health has full lifecycle solutions to prevent and mitigate reimbursement denials. The Experian Health intelligent ecosystem is a comprehensive solution to the untenable healthcare claims denials management process. These tools include: ClaimSource: Voted Best in KLAS Claims Management Clearinghouse 2023, this healthcare claims management software gives providers reimbursement visibility in real-time from one intelligent hub. This software helps providers handle the entire reimbursement cycle. The tool allows end-users to create custom work queues to manage claims more efficiently. It also automates claims, allowing the software to clean submissions before they send. Flagging features let billers know exactly what's wrong with a claim, so staff can repair the error. Ensuring clean claims lessens denials and improves cash flow. Claim Scrubber spots claim errors within 3 seconds, flagging the claim with an explanation of why it needs reworking. Intelligent algorithms identify undercharging to maximize payer-allowed amounts. For medical billers and coders, this tool quickly spots the root causes of claims denial, faster and more accurately than doing it by hand. Enhanced Claim Status connects billers quickly to denied, pending, returned-to-provider, or zero-pay transactions well before the EOB or Electronic Remittance Advice forms process. Instead of waiting 30- or 45 days to review a denied claim, this software lets teams see the problems online in real time. It's an immediacy that's been missing from both front- and back-end claims management processes, allowing real teaching moments for revenue cycle teams. Denials Workflow Manager: Eliminates manual processes and allows providers to optimize the claims process. Providers no longer review claims manually, instead using computer automation to optimize follow-up activities. Claims management teams can quickly identify and target the claims needing attention quickly. Powerful features leverage root cause analysis to identify trends leading to claims denials. These platforms easily integrate with existing practice management and electronic health record software. They work well together or ala carte to increase the accuracy of claims documentation to eliminate denials. A successful strategy for reducing claims denials starts with AI and automation software. Healthcare organizations can reduce the time spent processing rejections and improve A/R by flagging at-risk claims. Ultimately, healthcare claims management software solves the complexities inherent in these processes. Higher patient satisfaction and greater provider revenues are possible. Talk to Experian Health today to see AI in claims processing at work.

After a brief hiatus, the COVID-19 virus is reemerging, just in time for cold and flu season. According to the Centers for Disease Control and Prevention (CDC) July numbers show COVID-related hospitalizations are ticking upward. A spokesperson from the agency said this is the first notable acceleration of the illness in 2023. In these challenging times, healthcare providers prepare for the next COVID-19 surge. While the American healthcare system struggled just three years ago to cope with COVID-19 as a black swan event, these organizations now have the perspective that comes from hard-earned experience. They also have the potential benefit of time. It makes sense to take the lessons learned from the 2020 crisis and apply best practices to prepare for a COVID-19 resurgence. A new survey shows healthcare teams still struggling with burnout from the last COVID uptick. By leveraging technology and implementing best practices, providers can streamline processes, improve patient access, and alleviate burdens on healthcare staff. Let's explore how digital solutions such as online self-service scheduling, mobile-first registration, and patient portals can help healthcare organizations prepare for the next wave of COVID-19. COVID lesson #1: Online self-service scheduling offers key benefits for patients and staff During the previous COVID-19 outbreak, online self-service scheduling proved to be crucial in mitigating the spread of the virus. Not only did it improve the experience for patients and healthcare staff, but it also reduced the volume of visitors to emergency rooms and prevented sick individuals from congregating in waiting rooms. While self-service patient registration isn't just for a pandemic, COVID-19 clearly illustrated the critical need for digital patient intake solutions. A recent Experian Health survey showed seven of ten patients prefer self-service appointment scheduling. Forbes says, “Scheduling options are now a must-have feature for hospital and health systems…Health systems that do not offer online patient scheduling will not only be left behind but will be left out.” With the potential for an additional COVID upsurge in the future, health providers must also consider the benefits for staff of offering online patient scheduling options. They include: Fewer manual tasks associated with patient registration Real-time scheduling information that streamlines workflows Reduced patient no-shows Improves team communication and closes care gaps Automates unnecessary administrative functions COVID lesson #2: Mobile-first registration increases patient access and satisfaction The Experian Health State of Patient Access 2023 shows increasing the convenience of patient access is the quickest way to improve customer satisfaction scores. The survey showed access to provider care is challenging post-pandemic; four in ten say access has worsened because of scheduling. These challenges are always more daunting during high utilization—such as during the COVID-19 pandemic. As healthcare providers prepare for a COVID surge during flu season, adopting a mobile-centric registration accelerator solution can empower patients and streamline the registration process. Patients can complete registration safely and conveniently in their homes without spending time in a waiting room. Providers benefit from this online solution with reduced paperwork, automation of manual tasks such as appointment reminders, and a lightened workload. Implementing mobile-first registration not only improves patient satisfaction but also eases the burden on healthcare staff. Patients that use these solutions reduce practice call volumes by 50%. COVID lesson #3: Patient portals streamline communication and engage patients Harnessing technology to streamline processes and alleviate burdensome tasks is crucial. Patient portals are revolutionizing healthcare by empowering patients and lightening the load on the system. The pandemic accelerated the use of patient portals. In 2020, the National Institute of Health (NIH) found less than half of insured adults used these tools. Today, the usage of online patient portals such as PatientSimple is much higher—and on the rise. A recent national survey shows even seniors are getting into online patient portals to access healthcare information; 78% of people aged 50 to 80 now use at least one of these online hubs. Five years ago, researchers say just 51% of this population used these tools. Leveraging a patient portal now before cold and flu season makes sense. Patients can use patient portals to manage common tasks such as: Pay balances up front with an on-file credit card Set up payment plans View test results Generate price estimates View statements and test results online Apply for charity care Communicate with providers The latest research from Experian Health and PYMNTS says two out of three consumers use patient portals to “streamline the medical journey,” while the remainder say they'd use these tools if their provider offered them. Online patient portals increase access and convenience for healthcare customers. However, there are just as many arguments in favor of providers investing in patient portals to benefit their staff.As COVID-19 cases rise, patient portals serve as critical information hubs, streamlining communication between providers and the patients they serve. Self-service portals ease pressure on overburdened care teams and upfront administrative staff. They also integrate with electronic health records (EHRs), streamlining the flow of personal health information (PHI) between providers and patients. It's a more engaging and effective experience for patients that lightens providers' workloads. As we move toward increasing COVID cases this fall, patient portals will be vitally important for everyone involved in the patient journey—including the patients themselves. Learn how Experian Health is helping care providers streamline their efficiencies with digital software and prepare for the next COVID surge.

Patient collections go to the heart of the debate about mission versus margin. As healthcare providers navigate the delicate balance between their mission to heal and the need to run a successful business, optimizing patient collections becomes a critical challenge. The weight of asking patients for payment is not lost on providers, especially considering the financial burden many patients already face due to medical expenses. It doesn't help that healthcare providers understand patients' struggles with medical debt. A 2023 Consumer Financial Protection Bureau report stated, “Many people experience unexpected health shocks that affect their financial well-being as much as, or even more than, their physical health.” As of June 2021, the United States recorded $88 billion in consumer debt to hospitals; 58% of all consumer debt is healthcare-related. One recent Experian Health and PYMNTS report shows that one-fifth of patients experienced financial distress by spending more on healthcare than they could afford. With healthcare costs rising, patients and healthcare providers feel a great deal of pain around budget balancing. Rising co-pays affect consumers in tandem with healthcare providers experiencing declining reimbursement. It's an untenable situation, but healthcare providers are increasingly turning to four critical strategies driven by technology solutions to ease these collections conundrums. Four alternative strategies to optimize patient collections In this blog, we explore four key strategies fueled by technology solutions that help healthcare organizations optimize patient collections while upholding compassionate care. 1. Do ongoing reviews of patient finances with the possibility of charity eligibility in mind While the unemployment rate is currently low compared to pandemic numbers, providers need to remember that just a few years ago, four in 10 Americans were without work for 27-weeks or longer. Americans are still playing catch up, and the data tells us nearly half of patients who reschedule their healthcare appointment do so related to cash flow concerns. Healthcare providers can help by working presumptive charity screenings into their collection workflows throughout the patient journey. Experian Health's Patient Financial Clearance software uses advanced analytics and data to analyze individual patient accounts and determines their ability to pay. This technology allows front desk personnel to quickly choose the most appropriate financial pathway for each patient. Patient Financial Clearance brings healthcare personalization to the most delicate part of the provider/consumer relationship, allowing staff to adjust their approach to suit each patient's financial abilities. 2. Using automation to find patient payment coverage Manual processes for patient financial arrangements slow down registration and ultimately miss potential payment resources. Unidentified coverage opportunities leave hospitals with over $745 billion in uncompensated care costs annually. The solution lies within Experian Health's Coverage Discovery software. This tool automatically scans the patient's account throughout their healthcare journey, searching for alternative payment methods to help patients improve their financial burden. Luminis Health leveraged Coverage Discovery and found more than $240k in active coverage on average per month in 2021.  3. Implementing compassionate billing methods to improve the collections experience Streamlining the registration process while discovering payment resources are two critical ways to create a more compassionate billing process and improved patient experience. Nearly one-quarter of patients face an unexpected medical bill after care delivery. Creating transparency between provider billing and the patient requires better technology to build personalized payment plans. Collections Optimization Manager makes payment collections easier by creating data-driven payment plans and individualized communications for each patient. This software can fully integrate with commonly used provider systems to connect with the patient from start to finish. It's a smarter and faster way to collect patient payments. 4. Using data for better collections In healthcare, software applications are only as good as the data behind them. While healthcare organizations have relied on behavioral and demographic datasets, adding a layer of credit data informs the revenue cycle in a way that adds enormous financial value to these organizations. With tools like Collections Optimization Manager, unpaid accounts are monitored for changes in a patient’s contact information or ability to pay. When a patient becomes employed, pays off delinquent accounts, or shops for credit, the in-house staff or the collection agency working the account is notified.  These combined datasets lay the groundwork to inform the payment collections process. Case study: Using technology for better healthcare collections Healthcare organizations like Stanford Health Care leverage technology as part of their strategies to optimize patient collections—and improve the patient experience with their system. The provider handles over two million patients annually and uses Experian Health's Collections Optimization Manager software to improve their bottom line. The software analyzes individual patient data at the point of service, segmenting patient accounts on their ability to pay. The software recovered significant revenue for the system while creating a more personalized approach to patient payment requirements. Missing coverage at the front desk resulted in significant revenue losses for the system, unnecessarily shifting payment burdens to patients. With Coverage Discovery, the system uncovered patient reimbursement resources, eliminating the need to write off or send these accounts to collections. Together, these tools achieved stunning results: More than $4m in average monthly payments More than $1 million in efficiency gains Savings of nearly 700 hours monthly by automating customer account screening Nearly 30% of all Coverage Discovery reviews found patient payment resources Experian Health: providing strategies and compassionate, personalized software to optimize patient collections With millions of Americans struggling with medical debt, healthcare providers must proactively address the challenges surrounding patient collections. By embracing innovative strategies powered by technology, providers can strike a balance between compassionate care and financial sustainability. Optimize patient collections with Experian Health's coordinated ecosystem of intelligent technologies, designed to simplify healthcare, promote customer-centricity, drive data-driven decision-making, and generate sustainable revenue.

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

Finding previously unidentified insurance coverage is a high-stakes treasure hunt for healthcare providers. If patients are unaware of active coverage or eligibility for Medicare and Medicaid, they will be left footing a bill that could have been covered by a payer. If they can't afford it, their account may end up being written off to bad debt, and providers will miss out on reimbursement opportunities, leaving millions of revenue dollars on the table. Hunting down missing or forgotten coverage on the spot is a challenge for providers, particularly if the patient does not have a Social Security Numbers (SSN) or the payers in question do not use SSNs to verify eligibility. It's a problem worth solving though and can improve the patient financial experience while preventing avoidable revenue loss. The shift away from Social Security Numbers Historically, providers have used demographic information like Social Security Numbers (SSN) to verify patient identities and locate coverage information. Without a unique patient identifier, SSNs were a stable way to link a person's health information across multiple health systems and payers. However, the use of SSNs for identification and verification purposes has dropped in recent years due to concerns about patient privacy and the risk of identity theft: SSNs give identity thieves a mechanism to assume a person's identity and access financial information and health records illegally. Moreover, SSNs are unreliable identifiers, as it is possible for more than one person to use the same number. Recognizing the need for more secure and trustworthy identifiers, many payers have moved away from SSNs. In 2018, the Centers for Medicare & Medicaid Services began the process to remove SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards, replacing them with Medicare Beneficiary Identifiers (MBIs). These are now the primary means of checking a person's identity for Medicare transactions like billing, eligibility status and claim status. Similarly, many health plans also shifted away from using SSNs as primary identifiers, instead opting for member IDs or other secure identifiers to verify and track coverage for their members. Find billable coverage with historical data With demographic searches on the decline, providers need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage. Combining search best practices, multiple proprietary databases and historical information, Experian Health's Coverage Discovery® locates patients' billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process. In 2022, Coverage Discovery tracked down billable coverage in almost 30% of self-pay accounts and found more than $64.6 billion in corresponding charges. Closing the coverage gap caused by Medicaid disenrollment Coverage Discovery offers another important benefit: helping providers offer additional support to patients on lower incomes who find themselves without Medicaid, at least for a short time, following the end of continuous enrollment. As of July 2023, more than 1.6 million Medicaid enrollees were disenrolled. Providers can use the tool to confirm whether Medicaid coverage remains in place, or to uncover any additional billable government or commercial insurance that could give patients peace of mind. Patient Financial Clearance can also help screen patients for Medicaid eligibility before or at the point of service, then route them to the Medicaid Enrollment team or auto-enroll them in charity care if appropriate. Case study: Read the case study to find out how Luminis Health used Coverage Discovery to locate $240k in billable coverage each month. Leverage technology to locate unidentified coverage Thanks to advanced tools like Coverage Discovery and Patient Financial Clearance, it's much easier for providers to locate alternative coverage options for patients, using multiple sources of data. These tools leverage secure identifiers and comprehensive searches across databases, allowing providers to reclaim revenue that may otherwise go unclaimed, and reassuring patients that they won't be left holding an unexpected bill. Find out more about how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.

Too often, resource pressures force providers to treat revenue cycle management as a reactive process. But with avoidable denials leaving thousands of dollars on the table, fixing problems after the fact is often a more expensive strategy. Investing in prevention on the front end can help providers minimize the risk of future revenue loss. This article looks at how providers can use automated prior authorizations to drive front-end revenue cycle growth, and fix revenue leaks before the denial dam bursts. Understanding the front-end of the revenue cycle Revenue cycle management includes all the activities involved in making sure hospitals and health systems get paid for their services. The front end of the revenue cycle includes the non-clinical processes that take place before a patient receives care, broadly referred to as 'patient access.' This can be broken into four stages: Scheduling and registering for care, including checking all patient information is current and correct Verification of insurance eligibility and benefits, to ensure planned services will be covered by the patient's plan Obtaining prior authorizations, to prevent claim denials Collection of co-pays and deductibles from patients before or at the point of service. Billing and claims management workflows must be set up so patients, payers and front- and back-office teams can share the information needed to expedite reimbursement. Accuracy and efficiency are essential at each stage of the front-end of the revenue cycle to prevent bottlenecks, errors and delays down the line. The longer errors lurk in the workflow, the more opportunities they have to damage the health system's financials. Front-end errors lead to denied claims later and more work for back-end staff Prior authorizations are a prime example: failure to secure the correct authorizations for treatment or services ahead of time can result in claims being rejected by payers. Time-consuming rework compounds the loss with hefty staffing and outsourcing bills. By the time the provider gets the amended paperwork in order, they've lost all leverage with the payer. It's a major concern as denial rates increase. Here are a few common prior authorization pitfalls to watch out for: The patient provides incorrect insurance information, which means the provider may fail to seek authorization from the right payer Inefficient operations and poorly defined processes allow inconsistencies and admin errors, such as wrong billing codes or misspelled names, to pass through the system undetected Frequent changes to payer requirements can be missed, so providers are working with outdated information Authorizations aren't obtained for the patient's entire treatment plan, leading to rework and treatment delays. A survey by the Association for Clinical Oncology found that 96% of respondents had seen a patient's care delayed because of prior authorization issues. Beyond these worrying harms to patients, the survey also revealed that 47% of practices spent more than 40 hours a week dealing with authorizations. Exploring solutions that will speed up prior authorizations can mitigate or eliminate these errors and delays. Front-end revenue growth starts with efficient prior authorizations As one of the top three reasons for denials given by providers in the State of Claims 2022 survey, prior authorizations are a logical target for front-end improvements. Prior authorization software helps providers get ahead of the above pitfalls by flagging authorization requirements early. Patient access teams can detect and resolve potential errors before they escalate, reducing the risk of rejected claims and appeals. Neeraj Joshi, Director of Product Management, at Experian Health, says that one of the big struggles for healthcare providers is that the prior authorization process is often still manual: “Automation has gained traction in many tasks within the revenue cycle, from patient access to claims management, but shifting to automated prior authorizations could offer one of the biggest returns on investment. Manual authorizations are time-consuming, error-prone and, all too often, a source of miscommunication. Shifting to automated authorization management can eliminate these obstacles and fuel revenue growth.” Experian Health's online prior authorizations solution automates 100% of inquiries, saving valuable staff time. Status checks happen without user intervention. Patient and payer data is auto-filled automatically, and users are guided through the workflow and prompted to make manual interventions only when absolutely necessary. Users can have confidence in the accuracy of the pre-filled data because the tool taps into Experian Health's Knowledgebase, which stores and updates national payer requirements in real-time. Users can also customize local and community rules, so no requirements slip through the net. By reducing costly denials and lowering labor costs, these set the stage for sustainable growth throughout the rest of the revenue cycle. How online prior authorizations can improve end-to-end revenue management Obtaining prior authorizations more efficiently is just the first step toward building a thriving revenue cycle. The promise of fewer denials might steal the headlines, but the benefits of automation resonate throughout downstream processes. For example, an automated online system enhances wider pre-registration processes by giving staff real-time visibility into the likelihood of a treatment being authorized. Staff can verify approval instantly, rather than turning patients away at check-in. This also makes it easier to generate accurate, upfront estimates of what the patient will owe, so they can plan for their own financial obligations. A positive patient experience can lead to faster patient collections and higher retention rates, which both boost revenue growth in the long run. Another ripple effect comes from the early verification of patient and payer information. These processes can surface data errors that, if left unchecked, could impede effective claims and billing workflows. This shows how a single authorization can have an outsized effect on overall revenue management performance – and why it's so important to get authorizations right the first time. Front-end efficiencies lead to a more predictable revenue cycle Providers that choose to use prior authorization software can amplify the benefits by integrating it with other online and automated solutions. Experian Health's prior authorizations tool fits seamlessly with the eCare NEXT® revenue cycle suite, which automates the entire revenue cycle workflow from insurance eligibility verification to secure patient payments. The interoperability of these tools means data can be shared from one system to another with ease, and reports can be generated and viewed on a single dashboard. With better data and analytics, users can make better predictions about their revenue cycle performance and find opportunities for further improvements. Similarly, providers can leverage the predictive power of analytics with AI-based technology. Experian Health's new AI-driven claims management solution, AI Advantage™, uses AI to predict claims that are likely to be denied, based on historical payment patterns. It checks for any undocumented payer adjudication rules, including prior authorization requirements, to make sure no essential information is missing before the claim is submitted. In a recent webinar on the future of claims management, Skylar Earley from Schneck Medical Center shared his experience with the new technology. He attributes the tool's success to its ability to make increasingly accurate predictions: “Since implementing this technology, we're continuing to see AR days decrease at our organization. One result that we're really excited about is seeing the number of authorized outpatient visits increase by about 2.5%. For anyone that deals with prior authorizations and denials related to prior authorizations, this is incredibly promising.” As authorization requirements increase in volume and complexity, providers need to be proactive in their response. Automation and digital technology can arm providers with the data and tools they need to speed up prior authorizations and drive revenue growth from step one in the revenue cycle. Find out more about how prior authorization software can support efficient front-end revenue cycle processes by creating opportunities to maximize cash flow from the start.