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Healthcare can be a serious expense. Around half of U.S. adults find it difficult to keep up with the costs, according to research from the Kaiser Family Foundation. As a result, roughly 4 in 10 have delayed medical care or gone without it over the last year. That’s where patient payment estimates and price transparency come in. When discussed at the outset of care, it can help patients prepare their budgets and understand their payment options. Consider it a built-in opportunity for healthcare providers to increase patient satisfaction and collections. “We’re all patients, so we all know the struggles,” said Riley Matthews, Senior Product Manager at Experian Health. “There is real frustration when faced with personal health challenges. On top of that, you’re burdened with meeting financial responsibilities. There’s no upfront explanation or seamless user experience to guide you through the cost of those services.” How to approach patient payment estimates The best time to share cost estimates is before the patient receives care. Healthcare providers can frame it as a two-way conversation, where the patient can ask questions and understand their projected out-of-pocket costs. When pricing is unclear, the patient might forgo care altogether. That’s a lose-lose for both the patient and the provider. Price transparency tends to lead to a better patient experience. According to a recent study conducted by PYMNTS and Experian Health, those who aren’t aware of their financial responsibility beforehand are less satisfied than patients who are. It then comes down to calculating patient estimates that are accurate and reliable. Patient Payment Estimates from Experian Health provide a clear breakdown of their out-of-pocket costs for the recommended services. It’s a simple but empowering thing that can help patients feel more in control. When patients are engaged and know what to expect financially, providers are more likely to collect payments in a timely manner. The Patient Payment Estimates platform offers: Price transparency, including financial assistance options An improved patient experience that allows for mobile payments Increased point-of-service collections Helping patients understand their payment options Once patients have a clear cost estimate, you can shift the conversation toward their payment options. Some may prefer to pay their bill in full beforehand. Others may need a more flexible arrangement — otherwise, they could opt out altogether and seek better payment options elsewhere. According to the PYMNTS and Experian Health study mentioned earlier, nearly one in 10 patients used a payment plan for their most recent doctor’s visit. What’s more, many patients who use payment plans are highly interested in switching providers if it means a better payment experience. Payment plans are valuable because they bend to fit patients’ unique financial situations. They can also increase the collections rate for healthcare providers. Experian Health’s Collections Optimization Manager can help providers be more intentional with their collections strategy. It scores and segments patient accounts based on which ones are most likely to be paid. From there, it directs them to the right resources to make payments. It essentially uses account data to bump up collections. Giving patients what they want Experian Health’s State of Patient Access 2.0 survey drove home an important point for healthcare providers — patients want clear, transparent pricing, along with payment plans and easier ways to pay. It’s precisely why patient-centered payments are so important. The idea is to give patients realistic financial expectations and fast, convenient payment options. Doing so can increase patient loyalty and revenue. Online patient payment software answers the call. This type of patient-first digital solution can optimize communication between patients and providers and allow for simple online bill pay. Patients are managing much of their finances online these days, from their bank accounts and student loans to their mortgages and credit cards. PatientSimple is a secure online portal where patients can set up payment plans, update their insurance information, schedule appointments and more. As the healthcare industry evolves, the patient experience is growing right along with it. Digital solutions, which make room for transparent pricing, are part of that journey. Patient Financial Advisor is a prime example. It provides an accurate snapshot of costs and payment options in advance. Patients receive a personalized estimate based on their benefits information and the provider’s payer contracted rates and pricing. Patients are also directed toward secure payment options. When all is said and done, healthcare providers want to deliver excellent care while also hitting their revenue goals. Patient payment estimates can be a driving force in getting there. Discover how Experian Health can help healthcare organizations provide price estimates and create better patient experiences.

The medical billing software outsourcing market is experiencing historic growth as providers respond to patient demand for digital payment options. The market’s value is expected to grow by five times over the next decade, from $11.1 billion in 2021 to $55.6 billion in 2032, according to a recent Future Market Insights report.  The pandemic has been the main driver of digital transformation in healthcare billing, embedding patient expectations for the same friction-free experience that has become the norm in other retail environments. By implementing medical billing software and digital collections solutions, providers can offer patients the flexibility and choice they desire. They can also capitalize on operational efficiencies ­– but only if they choose the right tools. Without the time or resources to undertake these activities in-house, many revenue cycle management teams are starting to outsource, in order to optimize medical billing processes, reduce costs and improve the patient payment experience. Choosing the right medical billing software Digital solutions can support every step of the patient’s financial journey, from receiving initial pricing estimates to paying at the click of a button. What criteria should providers consider when evaluating solutions that cater to patient demands for a better payment experience? Here are a few to look out for: Automation – Digital solutions do more than simply remove the need for paper-based billing. Software and machine learning can complete tasks to reduce the burden on staff and patients. Patient payment reminders, auto-filled claims forms and coverage checks are just a few examples of how automation can deliver speed and simplicity to patients, while saving staff time. User-friendly interfaces – A digital tool that’s difficult to use is never going to gain traction. Whether patient-facing or for use by front or back-office staff, user interfaces should be clean, simple and intuitive. Tracking and reporting – Digital billing solutions should offer the ability to monitor progress and generate instant status updates on payments and claims. With real-time insights, staff can further optimize collections and reimbursements. Reliable and secure data – Software and digital solutions are only as good as the data on which they’re built. Fresh, accurate patient data is essential. Data should be held in standardized and interoperable formats to streamline data exchange between different electronic records management systems. This will help to avoid errors, keep data secure and ensure compliance with HIPAA. A single vendor – A piecemeal approach can result in tools that don’t speak to each other. Instead, it makes sense to select a vendor that offers integrated systems for greater reliability and ease of use. Information from multiple billing and claims tools can be pulled into a single dashboard, so staff can capture the details they need at a glance. Setting up and optimizing digital solutions can be easier with a single vendor too. That’s why Experian Health offers consultancy and technical support to help users get started quickly. Here are 4 medical billing solutions that check these boxes: 1. Generate accurate estimates during patient registration with Patient Payment Estimates Providers can set the tone for a positive financial experience by deploying digital billing solutions from the start of the patient journey. One example is to offer patients accurate estimates of the cost of care before or at the point of service, so they can concentrate on treatment without worrying about unexpected bills. Patient Payment Estimates give patients a breakdown of their financial responsibility along with information about relevant payment plans and links to convenient payment methods. These can be accessed via a web-based tool or sent straight to their mobile device. Given that 6 out of 10 patients who received inaccurate cost estimates would switch providers for a better payment experience, tools like these could deliver a strong ROI. 2. Verify coverage as early as possible with Insurance Eligibility Verification and Coverage Discovery Verifying a patient’s active insurance coverage is a painstaking task when undertaken by hand. Staff must pore over payer websites and call insurance agents to check what the patient’s plan will cover. Automated tools like Insurance Eligibility Verification and Coverage Discovery can identify coverage quickly and accurately. Not only does this reduce the patient’s financial responsibility, but it also lowers the risk of uncompensated care and saves valuable time for staff. 3. Submit clean claims the first time with Claims Management Software Automating claims management takes a huge amount of pressure off staff teams. It also guarantees a higher level of accuracy than if claims were managed manually. Claims management software can automatically add patient information to claims, incorporate customized edits and review coding to ensure claims are correct before they are submitted electronically. Claims adjudication can be monitored in real-time to reduce the risk of denials. 4. Provide personalized payment plans and point-of-service payment options with PatientSimple Ideally, bills will be settled as early as possible. Neither providers nor patients want a protracted process of overdue statements and repeated phone calls from collections agencies. If patients are offered a choice of convenient payment methods at each touchpoint, they’re more likely to pay before or at the point of service. PatientSimple leverages Experian Health’s unrivaled data to identify the most suitable payment pathway for each patient and helps them manage it through a user-friendly, self-service portal. Patients can view statements online and pay balances immediately with cards kept on file. With the right medical billing solutions, providers can alleviate pressures on staff, reduce the risk of errors and support compliance with new regulatory requirements. But more importantly, it creates a healthcare experience that’s efficient, flexible and simple for patients, resulting in higher consumer satisfaction and faster patient collections. Find out more about how Experian Health’s medical billing solutions help providers maintain a healthy revenue cycle and meet patient expectations for a 21st-century consumer experience.

Healthcare providers that fail to embrace automation and digital tools to optimize patient collections could be leaving money on the table. Patient financial responsibility is higher than ever; however, the number of patients that struggle to pay is increasing, with 3 in 10 patients saying they’d be unable to pay a $500 bill and nearly a fifth of patients with medical debt believing they would never pay it off. As patient payments account for a growing portion of revenue, providers cannot afford to rely on subpar collections processes. Manual and paper-based patient collections remain the standard for many providers, but the reality is these outdated methods are unreliable and inefficient. Billing is slow and vulnerable to errors, and staff loses valuable time to the many pitfalls of paperwork. Optimizing patient collections with data-driven automation and user-friendly digital tools is a much smarter approach to accelerating payments, improving recovery rates and reducing operating costs. Why providers need to optimize patient collections Collecting patient payments has long been a pain point for providers. Recent changes sweeping across the insurance landscape and economy have exacerbated the challenge. More patients are turning to health plans with higher deductibles, which may seem more affordable in the short term, but leave patients footing a greater portion of their healthcare bills overall. At the same time, these bills – along with most other household expenses – are increasing at a rate that outpaces salary growth. For providers, this raises the risk of uncompensated care. Until recently, most write-offs in patient collections were associated with uninsured patients, but the uptick in high deductible health plans has nudged the burden of debt toward insured populations. Rather than waiting until the final bill has been determined and then mailing out a billing statement to the patient, providers must shift their focus to the earlier stages of the collection process. If they can calculate exactly how much each patient owes and route their account accordingly, collections will be smoother and faster. The task of calculating patient financial responsibility is complex, though. Applying automation technology to tackle this challenge is no longer optional. Benefits of automating patient collections The digital revolution accelerated during the early stages of the COVID-19 pandemic. Scheduling and registration – which lay the groundwork for efficient patient collections – were managed through remote online self-service tools, while contactless payments became commonplace. The drivers of data and automation may have shifted now, but the benefits remain clear. Aside from the financial savings associated with transitioning to fully electronic transactions, automation facilitates operational efficiencies. Automation can counter staffing shortages in patient collections teams, by helping staff focus on the accounts most likely to pay. They can filter out bankrupt or deceased accounts and use automation to check charity eligibility. Automated dialing and texting can be used for more efficient patient communications. Optimizing billing and payments can also create a more compassionate experience and make it easier for patients to understand what they owe and how to pay, without the need for endless phone calls to patient collections teams. Providers should consider the following five steps to leverage data and automation for improved patient collections: Step 1: Establish clear financial policies for patient collections Streamlined collections begin with clear patient communications. Patients should be advised of payment policies as early as possible. For example, does a particular type of appointment have to be paid for at the point of service? Could they be eligible for a discount if they pay a larger bill sooner? When patients are fully informed of their financial obligations, it’s easier for them to plan. Automated upfront Patient Payment Estimates give patients an accurate idea of what they’re likely to owe, reducing the risk of missed or delayed payments. Automated data analytics can help providers tailor patient communications based on the patient’s preferred method of communication and offer the most relevant information when it matters most. Step 2: Prioritize point-of-service payments to optimize patient collections The longer a bill sits in accounts receivable, the less likely it will be recovered in full. Encouraging patients to pay as much of the bill as possible, as early as possible, helps improve recovery rates. This starts with verifying the patient’s insurance coverage. Giving the patient clarity about their coverage, co-pays and deductibles at the time of service reduce payment delays and confusion. For the Director of Patient Financial Services at Kaiser Permanente Northern California, applying automation in this way has helped staff and patients navigate a more complex coverage environment and drive up point-of-service payments: “At Kaiser, we’ve implemented financial assistance patient identity verification tools to help us identify what our members would be able to pay at the point of service, and how we would manage them on the back end if they end up with a patient balance. Before we had these tools, we were blind as to what our patients would be able to pay.” Step 3: Give patients personalized payment options Offering a choice of payment methods that patients can access anytime, anywhere, can also increase point-of-service payments. Patients repeatedly say they want flexibility, having grown accustomed to the digital and contactless payment methods used in everyday retail scenarios. Experian Health’s Patient Payment Solutions enable providers to accept multiple forms of digital and contactless payments, including eChecking, credit and mobile payments. Patients also welcome the option to spread out payments and set up automatic recurring payments to manage larger balances. Providers can deliver a more satisfying patient experience and accelerate collections by offering personalized payment plans. Data and automation help providers identify and deliver the best-fit options for each patient. For example, PatientSimple is a consumer-friendly self-service portal that identifies the best financial pathway for each patient and allows them to pay balances with ease. It also stores payment information so patients don’t need to input their card details every time they want to pay. Step 4: Use smart strategies to pursue bad debt Determining the best collection approach for each patient requires current and comprehensive insights into their financial situation. Collections Optimization Manager pulls together data to help providers prioritize accounts by payment probability. Communications regarding accounts with a high payment probability can be automated and managed through self-service options. Accounts that are less likely to be paid can be routed to collections agencies or managed in-house, to increase workforce productivity. Cari Cesaro, Senior Director of Enterprise Healthcare Consulting at Experian Health, explains how automated collections insights reduce bad debt: “We’re able to extract data from the accounts receivable file and produce robust analytics and insights. That allows us to screen or scrub out those accounts that we should not be scoring or segmenting. Then, we shift to the customized segmentation, which allows the client to better narrow down those accounts that represent the highest potential for payment and match these to their calling capacity in-house.” Step 5: Train staff to have compassionate conversations Finally, with the right data, staff can have more compassionate and useful conversations with patients about how best to manage bills. Medical debt is a growing concern for patients, and staff should be trained to handle these conversations sensitively. Providers can further maximize their collections strategy by training staff to use collections optimization software to its fullest potential. Staff may worry about the learning curve when transitioning from paper-based to digital processes. Experian Health’s Collections Optimization Manager is designed with a user-friendly interface for intuitive navigation. Staff can easily view reporting and benchmarking insights and identify opportunities to improve collection rates. Find the right revenue cycle management partner With support from a trusted revenue cycle management company, providers can improve patient payment collections for increased revenue and streamlined operations. Speak to Experian Health today to find out how our best-in-class solutions are helping healthcare providers optimize patient collections, reduce bad debt, boost recovery rates and deliver a stand-out patient financial experience.

More than 4 in 10 working-age adults do not have adequate healthcare insurance in 2022, according to a recent survey by The Commonwealth Fund. Half of those surveyed said they’d be unable to pay an unexpected medical bill of $1000 within 30 days, and 46% said they’d postponed care because of concerns about cost. Recent data from Experian Health and PYMNTS showed very similar findings. This means providers must take proactive steps to find missing health insurance for their patients or risk negative impacts on their bottom line. Aside from causing distress to patients and hindering access to prompt, effective care, inadequate insurance coverage also raises the risk of uncompensated care for providers. The American Hospital Association reports that hospitals have provided almost $745 billion in uncompensated care since 2000. What makes this even more frustrating is that in many cases, patients do have additional coverage that could help close the gaps, but they’ve either forgotten about it or are unaware of their eligibility. Hunting down this missing health insurance is a daunting challenge for healthcare providers, but is essential if they are to avoid giving away care. Unfortunately, the problem is likely to worsen as patient volumes increase, and pressure mounts on collections teams that are already stretched. Finding undisclosed active coverage should be a priority for providers who want to avoid more revenue slipping through the cracks. Watch the video to see how Coverage Discovery helps healthcare providers find previously unidentified coverage – while saving time and money. Why is tracking down active coverage so challenging? While the benefits of finding missing coverage are clear, doing so is less straightforward. In most cases, coverage has been forgotten because a patient has moved to a new house and/or state, changed employers, or experienced financial difficulties – all challenges that have been exacerbated by the COVID-19 pandemic. Patients may be misclassified as self-pay or as having only one form of insurance. In recent years, it has become more common for a patient to access care from multiple healthcare facilities, which adds layers of complexity to the reimbursement process and introduces more opportunities for data errors. Providers must also contend with regulatory changes, particularly regarding Medicaid and Medicare coverage. For example, Medicaid enrollment grew by 25% between February 2020 and May 2022. Now, up to 14 million people are set to lose that coverage as the continuous enrollment requirement winds down with the end of the COVID-19 public health emergency nearing. Some will seek coverage outside the marketplace; others may be eligible to re-enroll; others will go without, seeking charity assistance. Verifying active coverage in this context can be extremely resource-intensive and time-consuming for providers and their staff. How can providers find missing health insurance quickly and accurately? Providers can turn to automated digital solutions to ease some of these pressures. Coverage Discovery is the only comprehensive coverage identification solution that works across the entire revenue cycle. It searches government and commercial payers to find previously unknown insurance coverage in advance of scheduled appointments, at the point of service, and even after appointments have taken place. Using multiple proprietary data sources, advanced search heuristics and machine learning, it reliably identifies accounts that may be submitted for immediate payment under primary, secondary or tertiary coverage. Running repeated checks at various points in the revenue cycle means the value of Coverage Discovery builds over time. The Director of Patient Access at Essentia Health says: “We found 67% of coverage for accounts that were at self-pay or uninsured accounts at the time of pre-service and 33% at the time of post-service. We have found a total of 16,990 accounts since we went live on Coverage Discovery.” In 2021 Coverage Discovery tracked down previously unknown billable coverage in more than 27.5% of self-pay accounts representing more than $66 billion in corresponding charges. The business case is clear: collections and cash flow go up, while A/R balances, self-pay write-offs and charity care misclassifications go down. What else can providers do to help patients manage the cost of care? Clearly, patients benefit from collections processes that have the potential to reduce their financial responsibility. Reducing friction at the point of service and providing cost information upfront increases the likelihood of correct and timely payments, as well as helps consumers manage their financial obligations. Patients today want to play an active role in their healthcare journey, and that includes making financial decisions in addition to care choices. Tools such as Patient Financial Advisor, Patient Financial Clearance and PatientSimple work alongside Coverage Discovery to empower patients and streamline complex payment processes. By providing an efficient, user-friendly suite of digital tools and solutions, health services can ensure a compassionate patient financial experience, get paid faster and increase profits. The search for insurance coverage does not have to be complicated. Contact Experian Health to find out how Coverage Discovery makes finding missing health insurance easier.

In 2009, processing claims was listed as the second greatest contributor to “wasted” healthcare dollars in the US, at an estimated $210 billion. A decade later, that amount was estimated at $265 billion. Today, healthcare providers are still grappling with denied healthcare claims, with both challenges and solutions accelerated by the pandemic. To put the scale of operational and delivery changes into perspective, Experian Health recorded well over 100,000 payer policy changes for coding and reimbursement between March 2020 and March 2022. The implications for claims processing are immense, which is why healthcare providers need to reevaluate their denial management strategies and invest in new technology that can help increase reimbursements. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand how they feel about the current situation. What are the priorities of those on the front line of denials management? And how can technology contribute to improvements? This article breaks down the key findings. Takeaway 1: Denials are increasing and reducing them is priority #1 30% of respondents say denials are increasing by 10-15% Nearly 3 out of 4 respondents say that reducing denials is their top priority For most respondents, claims management is more important now than it was before the pandemic, because of payer policy changes, reimbursement delays and increasing denials. Respondents attribute this to insufficient data analytics, lack of automation in the claims/denials process and lack of thorough staff training. When it comes to improving denial rates, staffing seems to be the greatest challenge. More than half of respondents say staff shortages are slowing down claims submissions and hampering efficiency. Shrinking offices mean there is less staff to handle the growing volume and complexity of claims. It’s no surprise, then, that around 4 in 10 respondents are also concerned about keeping up with rapidly changing payer policies and keeping track of pre-authorization requirements. Providers recognize that technology can help reduce denials while easing the burden on staff. A tool like ClaimSource manages the entire claims cycle using customizable work queues that make it easy to prioritize accounts, saving staff time and avoiding the errors that lead to denials. This also incorporates payer edits to ensure that claims are clean before being submitted to the payer. And if claims do end up needing further attention, Denials Workflow Manager eliminates time-consuming manual processes and allows providers to attend to high-risk claims quickly, so there’s less chance of delayed reimbursement. Takeaway 2: Automating denials management in healthcare is critical 52% of respondents upgraded or replaced previous claims process technology in the last 12 months 51% are using robotic processes, including automation, but only 11% are using artificial intelligence Prior to the pandemic, automation was sometimes perceived as a threat to jobs. But with changing employment patterns and evidence of the broader benefits of automation, attitudes are shifting. Automation can make life easier for staff by removing manual tasks to allow them to focus on other priorities. It speeds up the healthcare claims processing workflow, reduces the risk of errors, and enables better communication between providers, patients and payers. Providers recognize that automation drives more efficient claims management. The survey revealed that 45% of respondents turned to automation to keep track of payer policy changes, 44% had automated patient portal claims reviews, and 39% had digitized patient registration in the last year. Automation supports all stages of the claims management process, from auto-filling patient data during registration, to generating real-time claim status reports for back-office staff. Payer authorizations were a common challenge for providers, and a perfect fit for automation. Experian Health’s Prior Authorizations solution eliminates the need for staff to visit multiple payer websites, automates inquiries, and offers real-time updates on pending and denied submissions so staff knows when to intervene. Takeaway 3: Providers are searching for denial management solutions that will achieve the greatest ROI 91% of those likely to invest in claims technology say they will replace existing solutions if presented with a compelling ROI The majority of providers may be on the lookout for better claims management solutions, but they vary in how they measure ROI. Predictably, one of the most common metrics is how much staff time can be saved, with 61% concerned with hours spent appealing or resubmitting claims, and 52% looking at time spent reworking claims versus reimbursement totals. Rates of clean claims and denials were also popular metrics, at 47% and 41%, respectively. Using Denials Workflow Manager and ClaimSource alongside additional claims management solutions like Claim Scrubber and Enhanced Claim Status can deliver an even stronger performance against the above metrics. Each solves a specific challenge within the claims management workflow, but when used together, the ROI is multiplied. Overall, there’s optimism that digital technology and automation can help healthcare providers improve claims and denial management and reduce the amount of “wasted” dollars. This survey shows that providers are keen to grasp the opportunities offered by automation to optimize the reimbursement process and get paid sooner. Download the report to get the full results on the State of Claims 2022, and discover how Experian Health can help organizations with their denial management strategies.

Full implementation of the Appropriate Use Criteria program has been indefinitely delayed, giving providers more time to prepare. The Centers for Medicare and Medicaid (CMS) introduced the consultation mandate to ensure that advanced diagnostic imaging services would be provided to Medicare beneficiaries only where medically necessary. Originally slated to commence in January 2022, the penalty phase had already been pushed back until January 1, 2023, at the earliest, due to logistical challenges and concerns about the administrative burden on providers. While penalties for non-compliance won’t kick in just yet, claims submitted before full implementation could still be subject to denial. Providers should take advantage of the extended educational and operations testing period to stress-test their pre-claims infrastructure for any Medicare claims that would fall under the program or that require other forms of pre-authorization. This means implementing alerts to comply with the Appropriate Use Criteria program and prior authorizations requirements To support providers to manage these changes, Experian Health’s Prior Authorizations solution now includes informational alerts for Medicare plans where a patient order needs to comply with AUC or requires prior authorization. Recap: what the Appropriate Use Criteria program means for providers The AUC program requires providers to consult a Clinical Decision Support Mechanism (CDSM) any time they want to order specific advanced diagnostic imaging services for certain Medicare outpatients. The CDSM online portal will check the patient’s record to confirm whether AUC requirements apply. The ordering physician must pass on this information to the imaging services provider. Any physicians whose ordering patterns are considered outliers will need to seek prior authorization. The process for this hasn’t yet been determined. To secure reimbursement for diagnostic imaging services, imaging service providers will need to have the appropriate certificate of compliance. This means that while the administrative responsibility lies with the ordering provider, the financial consequences of non-compliance sit with the service provider. That may or may not be the same facility. Clear communication, robust records management and interoperable data will be essential to avoid claim denials. Pitfalls of manual prior authorizations and pre-claim reviews Many healthcare providers still rely on manual paperwork for prior authorizations and pre-claim reviews. However, these processes are inefficient and prone to error, especially as claims increase in volume and complexity. The Council for Affordable Quality Healthcare (CAQH) estimates that manual status inquiries take up to 30 minutes each, with automated alternatives reducing this by up to a third. The financial impact is compounded by staff time wasted on unnecessary rework, non-compliance penalties and denied claims. Automated compliance checks can help ensure that no pre-claim requirements are missed. With tools such as Experian Health’s online prior authorizations solution, claims are more likely to be complete and compliant, denials will be less likely, and staff will be able to work more efficiently than if they attempt the process manually. This online service automates prior authorization inquiries with auto-filled payer data, only prompting users when their involvement is needed. Inquiries take place behind the scenes, using dynamically updated knowledgebase stores. Now, the knowledgebase will facilitate quick checks to see if a procedure also requires AUC adherence and alert users accordingly. Enhanced automated pre-claim checks for cleaner claims the first time The new informational alerts are the latest enhancement to Experian Health’s pre-claim management solutions to help providers stay compliant. Earlier in 2022, the Medical Necessity application was adapted to include informational alerts when a procedure needs AUC adherence or prior authorization for Medicare patients. Medical Necessity prevents denials and fines by automatically validating medical necessity checks for Medicare claims. Beyond requirement checks for Appropriate Use Criteria and prior authorizations, automation can also be used to improve other aspects of claims management increase claim accuracy and avoid denials. For example, Claim Scrubber reviews each claim line-by-line, verifying that the claim is coded correctly before it’s submitted to the clearinghouse or payer. Claim Scrubber generates general and payer-specific edits, which now also include AUC adherence checks. Users receive alerts with detailed explanations of why a claim was flagged, so modifications can be made before the claim is submitted. These tools integrate seamlessly with electronic medical record systems so claims and patient orders can be checked against payer rules for medical necessity, frequency, duplication and updated modifiers, and to ensure patient information is current. This also facilitates a more reliable exchange of information between all those involved in the provision and reimbursement of healthcare services. Not only does this promote compliance with Medicare rules and reduce the risk of penalties and denials, but it also promotes better communication between healthcare organizations to deliver high-quality care and a better patient experience. Find out more about how Experian Health’s enhanced pre-authorization solutions support better claims management and help healthcare providers comply with Appropriate Use Criteria and other prior authorizations requirements.