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The denial challenge is getting tougher. In Experian Health's latest State of Claims 2024 survey, almost three-quarters of healthcare administrators agree that claim denials are increasing. The majority also agree that difficulties with claims—like reimbursement times, errors, and payer policy changes—are becoming more common. It's no surprise that denial prevention is a priority for 84% of respondents. However, many organizations still focus on reactive strategies, like working harder with denial management teams or appealing claims once the denial comes through. These efforts have their place, but they only address the problem after it occurs. It's a time-consuming, costly and ultimately inefficient way to face the denial challenge overall. A better approach is to figure out how to prevent claim denials in the first place. This article looks at how to build a proactive denial prevention strategy using automation and artificial intelligence (AI), to streamline claims processing and nip denials in the bud. Understanding denial prevention in healthcare Preventing denials starts with understanding the “ins and outs” of the claims process, particularly payer requirements. Denials occur when a payer refuses to reimburse a provider for services rendered, often due to avoidable coding errors, missing documentation or procedural mistakes. When that happens, providers are left to rework the submission or look elsewhere – most likely to the patient – to fill the funding gap. Many are simply written off to bad debt. To avoid receiving an 835 file with the dreaded claim denial notice, providers must focus on the root causes of denials and get ahead of the pitfalls. The importance of claim denial prevention With denial rates exceeding pre-pandemic levels, 42% of survey respondents say the economy and declining consumer confidence make payer reimbursements more urgent. While financial stability is the obvious driver for getting claims right the first time, denial prevention also improves operational efficiency and reduces the billing and coding staff workload. Denials are frustrating for patients and staff. When claims are processed correctly the first time, providers avoid delays and billing complications and reduce patient stress over unexpected costs. Preventing denials is critical for maintaining trust and ensuring patients feel secure about their financial obligations. How to prevent claim denials Denial prevention strategies should start with addressing the underlying causes of denials. Here are five denial prevention strategies to consider: 1. Improve data accuracy from the start Garbage in, garbage out. If patient information, insurance eligibility, prior authorizations and billing codes are input incorrectly or missing altogether, providers will continue to submit error-filled claims that have no hope of being paid. Tools like Registration Accelerator and Patient Access Curator can verify relevant data for accuracy before claim submission and reduce the risk of denial. 2. Use AI and automation for efficiency If there was ever a case for using automation and artificial intelligence, it's in claim denial prevention. However, around half of providers are still using manual processes, leaving them playing catch-up to the payers who are already using AI to work at scale. Only 10% have automated the process, using AI to correct and resubmit claims. Tools like ClaimSource® can automate eligibility verification and coding, perform error checks before submissions and ensure claims meet payer requirements instantly. This cuts the time and effort wasted on manual processes, releasing staff to focus on activities that need human attention. 3. Automate pre-claim scrubbing to catch errors A great use case for automation is in providing an extra pair of eyes to pore over claims and catch common errors like missing data and wrong codes before submission. Experian Health's Claim Scrubber analyzes claims line by line to ensure that claims are submitted to payers and clearinghouses without errors, increase first-time pass rates and prevent rebilling. 4. Track performance for ongoing improvement Every denial prevention strategy should include monitoring and reporting. Tools that offer real-time tracking of key performance indicators such as denial rates, clean claim percentages, resubmission times, and the reasons for denials can help staff identify patterns. With these insights, they'll have complete visibility into any recurring problems clogging up their claims processes. 5. Outsource to a trusted vendor for extra support and expertise Finally, providers might consider outsourcing denial prevention to a specialist vendor who can help them develop the right strategy and toolkit to streamline billing, improve data integrity and manage claims to ease pressure on internal resources. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Proactively reducing claim denials These strategies raise an important question: can existing revenue cycle technology handle the increasing volume of denials? Healthcare administrators aren't convinced: only 54% of survey respondents feel their organization's technology is sufficient to meet demand, down 23 percentage points since 2022. To implement these denial prevention strategies effectively, providers may need to consider upgrading their toolkit rather than relying on traditional systems. Experian Health offers two AI-powered solutions that help providers better predict and prevent denials: Prevent denials with Patient Access Curator  Too many denials originate in patient access, so prevention must start here. Patient Access Curator uses AI-driven data capture technology to verify patient details quickly and accurately. With a single click, PAC can automatically check eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, coverage discovery and financial status. Running multiple manual queries is a thing of the past, saving staff hours and propagating clean data throughout the entire revenue cycle. Watch the webinar to learn more about how Patient Access Curator helps prevent denials with accurate data from the start. Predict denials with AI AdvantageTM Clean data sets the stage for denial prevention, but AI adds an extra layer of protection by forecasting potential issues before it's too late. AI AdvantageTM does this in two ways. First, the Predictive Denials component analyzes claims using the provider's own ClaimSource® data and alerts staff to high-risk claims so errors, inconsistencies or missing documentation can be corrected before submission. Next, the Denial Triage component prevents missed revenue opportunities by segmenting denials and guiding staff to those worth reworking. See how AI Advantage works: If providers can't prevent denials, they can't protect their bottom line. With the right data analytics, automation and AI, providers can take control and spot issues before they become problems instead of spinning their wheels in endless rework. With more advanced tech on their side, it's possible to close the gap with payers and prevent denials, but it also gives staff the headspace to focus on patient care and support. Find out more about how Experian Health's Claims Management solutions help providers build effective denial prevention strategies and reduce lost revenue. Learn more Contact us

According to a new report by the American Hospital Association, administrative costs now make up over 40% of total hospital expenses. Hospitals and health systems spend around $40 billion annually on billing and collections alone. For revenue cycle managers, the pressure is building as administrative tasks like insurance eligibility verification, claims management and payment processing overwhelm their teams and drain budgets. However, a sizeable chunk of these costs—perhaps as much as $18.3 billion—could remain in hospitals' hands if certain administrative tasks were automated. Automating key revenue cycle management (RCM) workflows improves efficiency, accuracy and cash flow, while easing staff stress and expediting patient care. Could it be the secret weapon to alleviating administrative burdens? This article looks at the issues in further detail, and explores 5 use cases that show how automation can reduce administrative costs in healthcare. Understanding administrative costs in healthcare Spending on healthcare administration in the U.S. has risen from $654 per person in 2013 to $925 in 2021. Administrative costs cover the resources needed to manage the non-clinical aspects of care. These resource requirements are immense in a complex system with multiple payers, fragmented data systems and growing regulatory demands. Add persistent staffing shortages and increasing patient volumes to the mix, and it's easy to see how costs spiral out of control – especially when relying on inefficient systems. The billions of dollars and hours of staff time consumed by administrative tasks make it clear that resources are not being used most effectively. This is where automation can make a difference. The role of automation in healthcare Automation reduces human errors, speeds up workflows and accelerates cash flow. It frees up time, money and headspace to optimize services and improve patient experiences. It's no wonder it's gaining traction in revenue cycle management. However, many providers are not fully capitalizing on automation's potential: Experian Health's latest State of Claims 2024 report shows that fewer healthcare administrators feel their organization's technology is sufficient to meet RCM demands compared to two years ago. How can they tap into the benefits of automation to reduce administrative costs? Benefits of automation and how it can reduce administrative costs in healthcare Automating healthcare administration is about doing more – and better – with less. Some of the benefits include: Fewer errors in billing, coding and claims management. Fewer mistakes mean fewer denials, which translates to faster payments and less rework. Reducing time to get paid, as automated processes speed up claim submissions, insurance verification and payment collections. Cash flow improves and staff spend less time chasing payments. Alleviating staffing shortages, as automation takes care of repetitive tasks like data entry, payment reminders and reporting. Management can reduce the burden on overworked staff and curb training costs, while teams can focus on “value-added” work. Improving efficiency in every corner of the revenue cycle. Automating routine tasks makes the entire billing and revenue cycle process more efficient, allowing teams to handle more work in less time without increasing headcount. Happier patients (and a better-looking bottom line). Automation makes it easier for patients to understand their bills, set up payment plans and pay their balances online. Satisfied patients are more likely to pay on time, reducing the cost of chasing overdue payments. Implementing automation in healthcare When it comes to reducing administrative costs, selecting the right parts of the workflow to automate is key. Here are five possible use cases to consider: 1. Streamline insurance eligibility checks “Checking if my insurance was accepted was a fast and friendly process. The staff even helped clarify which insurance was the right one for me since I had multiple cards.” This is what one patient at Providence Health said, after the health system switched to automated insurance eligibility verification. Insurance Eligibility Verification connects to over 900 payers and automatically checks patients' coverage and plan-specific benefits information in real-time. This reduces the manual effort required by staff and prevents the delays and denials that lead to additional administrative costs. As the patient notes, it means patients get early clarity about how their care will be funded, so there are no surprises later. Read the case study: How Providence Health found $30M in coverage and reduced denials with automated eligibility checks. 2. Automate claims submission More than half of healthcare administrators say that claims errors are increasing. A quick win would be to use automation to pre-fill patient data and avoid the inconsistencies and typos that occur with manual input. A more significant gain could come from combining multiple automations to populate, check and track claims submissions. Tools like ClaimSource® can automate the entire claims cycle in a single application. Indiana University Health (IU) utilized ClaimSource to process $632 million in claims transmissions in just one week, after a halt to their operations. Summit Medical Group paired Claim Scrubber with Enhanced Claims Status to improve claims submission. Claim Scrubber ensures all claims are complete and accurate before being sent to the payer, and generates alerts so staff can intervene quickly if an error pops up. Enhanced Claim Status automatically pings payers for status requests so staff can spend less time seeking updates and accelerate follow-up activities. With this approach, Summit boosted their first-time pass-through rate to 92% and reduced accounts receivable days by 15%. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more 3. Improve denial management Denials remain one of the biggest pain points for providers. Payers are miles ahead in their use of automation and artificial intelligence (AI), using sophisticated machine learning tools to process and deny claims at scale. Experian Health's flagship AI-powered denial management solution, AI AdvantageTM, can help close the gap. This tool “learns” from an organization's historical claims data and trends in payer behavior to predict the probability of denial. It also identifies and segments denials so staff can prioritize those with the highest chance of being reimbursed, reducing the time and cost of manual appeals and rework. 4. Accelerate patient payments On the patient side, automation can be deployed to send patients reminders about outstanding balances, set up payment plans and process payments quickly and securely. Simplifying patient billing makes it easier for patients to pay, which increases collections rates while reducing the need for follow-up calls. Read more: 5 ways patient payment software improves patient satisfaction 5. Generate better financial reports Another smart use case for automation is generating real-time revenue cycle performance reports. With advanced data and analytics, staff no longer need to spend hours compiling information, while managers get faster, reliable information to inform strategic decisions. Experian Health's healthcare data analytics turns raw data into business-ready information to find potential sources of revenue leakage and boost financial performance. The future of healthcare automation Automation is already helping reduce administrative costs in healthcare by relieving staff of the tedious, time-consuming, repetitive tasks that drain time and money. However, many still rely on old data systems that don't work well together, leaving revenue opportunities slipping between the cracks. Choosing solutions that improve integration and interoperability will continue improving data-sharing between platforms and services, further reducing errors and delays. Looking ahead, automation and AI will play an increasingly major role in handling complex tasks in revenue cycle management. RCM leaders will find even more opportunities to minimize manual intervention and lower administrative overheads as these tools evolve. Learn more about how Experian Health's automated Revenue Cycle Management solutions help reduce administrative costs in healthcare and create more resilient revenue cycles. Learn more Contact us

Improving patient access is often a heavy lift for healthcare providers thanks to staffing shortages, lack of thorough staff training, inefficient processes and more. Experian Health's State of Patient Access 2024 survey found that curating accurate patient information also continues to be a challenge, which is the primary cause of denied claims for almost half (49%) of healthcare providers. Meanwhile, patients themselves are growing frustrated and are increasingly demanding better access. The same Experian Health survey revealed that patients want self-service, on-demand mobile scheduling, faster access to doctors and more digital channels for managing their healthcare. They also want more communication, faster service and easy-to-use digital platforms. After all, why shouldn't managing access to healthcare be as easy as booking a flight online? Here's a closer look at some of the key findings: 89% of patients want self-service scheduling 85% dislike manually filling out repetitive intake paperwork 96% want a cost estimate before their treatment Unfortunately, today's healthcare industry is often plagued by a highly complex interplay between people, processes, environment and technologies. Providers are hamstrung by outdated and siloed procedures. From laborious patient registration to by-hand claims processing, workarounds and manual tasks are inherent in their systems – making it challenging to fully meet patient needs. The new healthcare rally cry: Better patient access It's clear that an innovative response to revenue cycle management and patient access is needed, and needed soon. Providers have heard the message from patients – they want more self-serve access, like streamlined scheduling, on-demand service and user-friendly technology. That's where patient access software comes in. How patient access software benefits patients By leveraging modern digital tools, patient access software offers patients more speed, convenience and control over their healthcare experience. Patients now have 24/7 access to live online appointment scheduling, registration forms, test results, bill pay and more. Automated patient estimates provide clear, upfront information about the cost of medical services. Patients can also use this software to communicate with their providers. When patients feel more involved in their healthcare journey, outcomes tend to be better, too. Here's a closer look at how patient access software helps patients: Online patient scheduling offers self-service convenience and the flexibility to schedule from any digital device. Patients can reschedule or cancel appointments online. These tools eliminate the need for lengthy office phone calls and allow patients to book appointments at their convenience. Patient intake solutions create better registration experiences by allowing patients to complete registration forms anywhere and anytime. This makes check-in easier and faster. Better technology streamlines the patient experience by removing the frustration of repetitious, manual paperwork. An Experian Health study showed that patients spend an average of $675 a year on surprise medical bills, with nearly half spending more than they can afford, thanks to inaccurate estimates. Tools like Patient Financial Advisor can help patients get accurate out-of-pocket estimates, while providing them with personalized payment plans and the ability to pay bills online. What's in it for providers? Better patient access solutions offer healthcare providers countless benefits. In addition to fostering continuous engagement with patients, providers benefit from streamlined administrative processes, reduced appointment no-shows and optimized scheduling. Plus, facilitating better patient engagement and satisfaction tends to improve health outcomes and strengthen patient-provider relationships. Providers that leverage AI and automation also reduce the burden on overworked staff and enhance revenue cycle efficiency, eliminate error-prone manual entry and increase revenue. Here's how implementing patient access software helps healthcare providers: Automated insurance verification and eligibility tools eliminate the costly human errors that cause claim denials and payment delays. These platforms can verify a patient's insurance coverage and benefits in seconds, ensuring accurate reimbursements and lower bad debt. Electronic prior authorization solutions automate pre-authorization inquiries and lessen the volume of claim rejections. Pre-authorizations are one of the three most common reasons for reimbursement denials. Patient payment estimates provide clear, upfront information about the cost of medical services. These tools create a sense of accountability in patients who understand their financial responsibilities before receiving care. Automating this step at patient intake reduces the administrative burden on healthcare staff. It also increases the likelihood that providers get paid and sets the stage for more effective collections when needed. Improved patient access is a win-win, and better technology is at the heart of patient-centered healthcare. Patient access software is integral in enhancing the efficiency of healthcare delivery, improving patient satisfaction, and optimizing the revenue cycle for healthcare providers. These solutions encompass a variety of technologies and processes designed to facilitate better communication, streamline administrative tasks and ensure timely access to care. Experian Health offers a suite of patient access software that streamlines the entire patient journey from start to finish.  Contact us to learn how these solutions can help healthcare organizations reduce manual errors, decrease claim denials and improve patient experiences.  Patient Access Software Contact us

Claim denials are a well-documented challenge for healthcare organizations. Denied claims take much longer to pay out than first-time claims, if they get paid at all. Each one means additional hours of rework and follow-up, pulling in extra resources as staff review payer policies and figure out what went wrong. It's time-consuming and costly. Beyond dollars and paperwork, denials affect patient care as uncertainty about payments leads to delays in treatment or unexpected out-of-pocket costs. But how do healthcare leaders feel about the state of claims management today? How are they tackling the administrative burden? Is there any light at the end of the denials tunnel?   Experian Health surveyed 210 healthcare revenue cycle leaders to find out. The 2024 State of Claims report breaks down the survey findings, including insights into how automated claims technology is being used (or not!) to optimize the claims process and bring in more revenue. What is the current denial rate for healthcare claims? 38% of survey respondents said that at least one in ten claims is denied. Some organizations see claims denied more than 15% of the time. That's a lot of rework and lost revenue that providers were counting on. In 2009, claims processing accounted for around $210 billion in “wasted” healthcare dollars in the US. A decade later, the bill had climbed to $265 billion. Industry reports—including Experian Health's State of Claims series—repeatedly observed a rise in denial rates. Today, 73% of providers agree that claim denials are increasing, while 67% feel it's taking longer to get paid. Providers constantly worry about who will pay – and when. What are the most common reasons for healthcare claim denials? According to the State of Claim survey respondents, the top three reasons for denials are missing or inaccurate data, authorizations, inaccurate or incomplete patient info. In short? The problem is bad data. Given how much information has to be processed and organized to fill out a single claim, this isn't surprising. From patient information to changing payer rules, the sheer volume of data points to be collated creates too many opportunities for errors and omissions. On top of that, the rules are always changing. More than three-quarters of providers say payer policy changes are occurring more frequently than in previous years, making it increasingly difficult to keep up. Other challenges, such as coding errors, staff shortages, missing coverage and late submissions still play a role, but it's clear that solving the data problem could make a meaningful dent in the denials problem. Read the blog: How data and analytics in healthcare can maximize revenue Could automation improve claim denial statistics? To help end the cycle of denials, more healthcare providers are turning to claims management software to resolve or prevent the snags that interfere with claims processing and billing workflows and boost claim success rates. That said, around half of providers still review claims manually. Despite the proven benefits of integrated workflows and automation, the drive to implement new technology during the pandemic seems to have lost momentum: the number of providers currently using some form of automation and/or artificial intelligence (AI) has dropped from 62% in 2022 to 31% in 2024. Could this be down to a lack of comfort with how new technologies work? Only 28% feel confident in their understanding of automation, machine learning and AI, compared to 68% in 2022. For those who are curious but cautious, here are a few ways claims automation can help improve claim denial statistics: Connect the entire claims process end-to-end: Using an automated, scalable claims management system like ClaimSource® helps providers manage the entire claims cycle in a single application. From importing claims files for faster processing to automatically formatting and submitting claims to payers, it simplifies the claims editing and submission process to boost productivity. Submit more accurate claims: 65% of survey respondents say submitting clean claims is more challenging now than before the pandemic. There's a strong case, then, for using an automated claim scrubbing tool to reduce errors. Claim Scrubber reviews pre-billed claims line by line so errors are caught and corrected before being submitted to the payer, resulting in fewer undercharges and denials and better use of staff time. Improve cash flow: Automating claim status monitoring is one way to accelerate claims processing and time to payment. Enhanced Claim Status eliminates manual follow-up so staff can process pended, returned-to-provider, denied, or zero-pay transactions as quickly as possible. Eliminate manual processes: While there are some tasks that genuinely need a human touch, too much staff time is wasted on repetitive, process-driven activities that would be better handled through automation. Denials Workflow Manager automates the denial process to eliminate the need for manual reviews. It helps staff identify denied claims that can be resubmitted and tracks the root causes of denials to identify trends and improve performance. It also integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so staff can view claim and denial information on a single screen. Experian Health was client-rated #1 by Black Book™ '24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Improving claim denial statistics with AI While automation speeds up the denials workflow by taking care of data entry, AI can look at that data and recommend next steps. Current ClaimSource users can now level up their entire claims management system with AI AdvantageTM, which interprets historical claims data and payer behavior to predict and prevent denials. The video below gives a handy walk-through of how AI Advantage's two offerings, Predict Denials and Denial Triage, can help providers respond to the growing challenge of denials: As the survey shows, there's a growing need for easy-to-implement solutions to the denials challenge. While progress has been made, the findings suggest there's still room to use automation and AI more to prevent denials and level the playing field with payers. Download Experian Health's 2024 State of Claims report for an inside look at the latest claim denial statistics and industry attitudes to claims and denials management. 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Health payers created the prior authorization system as a cost and quality control strategy, ensuring patients receive only the most necessary, evidence-based, cost-effective and quality care. Nevertheless, real-life implementation has shown that prior authorizations often backfire on their original intents, increasing overall care costs beyond what is necessary. It also delays patient care, contributes to physician burnout and hinders operational efficiency.  Additionally, dealing with the administrative workload associated with prior authorizations can be overwhelming, time-consuming and exhausting for providers and billing teams. The sheer volume of paperwork required to navigate the traditional prior authorization system can be exhausting, particularly given the current climate of staff shortages and constantly changing payer policies.   Read on to learn why prior authorizations are crucial to reimbursements and how healthcare organizations can streamline the process using electronic prior authorizations.  What are prior authorizations?   Prior authorizations, also known as preauthorizations, is a process that involves healthcare providers obtaining approval from a health plan for a service or prescription to be delivered to a patient. This approval ensures that the plan reimburses the cost of the service or prescription.   Prior authorizations involve a series of steps. First, healthcare providers confirm the patients' qualifications for the proposed treatment. Next, they determine whether prior authorization is required. If an authorization is necessary, providers must submit information detailing the patient's medical history and other administrative information. They also have to submit supporting documents to justify the necessity and appropriateness of the proposed treatment. If the submission meets the prior authorization criteria, the plan approves the request and reimburses the cost of care.  Payers develop prior authorization criteria drawing from medical guidelines, cost considerations, utilization data and other relevant information. However, according to an American Medical Association (AMA) survey, more than one in three providers claim that these rules are rarely or never evidence-based.  Why are prior authorizations required?  Payers created prior authorizations to ensure that the specific service delivered to the patient is medically necessary, appropriate and in line with evidence-based guidelines. It is a cost-and-quality control mechanism. It is set in place so patients only receive the best and most cost-effective care option, optimizing quality while controlling costs.   Prior authorizations have been suggested to help manage the cost of care and reduce healthcare spending. Payers employ prior authorizations to prevent the arbitrary prescription of expensive treatments and medications to patients without appropriate justification. For instance, a healthcare provider might prescribe a costly brand-name medication for which a generic and more cost-effective alternative exists.  The prior authorization requirements regulations also ensure that healthcare providers administer evidence-based care and prescribe FDA-approved medications. In cases of off-label use, the requirements help encourage providers only to prescribe treatments supported by high-quality scientific literature. These medications must also meet indications endorsed by recognized sources such as the American Hospital Formulary Service Drug Information (AHFS-DI).  Challenges with traditional prior authorization methods  For many providers, dealing with prior authorization is an endless journey of starting, completing and revising paperwork. This process presents administrative challenges, leading to a significant waste of time and resources. An AMA survey found that 86% of physicians have reported that prior authorization increased healthcare resource usage.   Healthcare providers frequently allocate a large portion of their daily schedules to addressing prior authorizations. This practice takes staff time and effort that could otherwise be dedicated to providing high-quality patient care. According to an AMA prior authorization survey, healthcare providers spend about 12 hours working on 43 prior authorizations weekly. Not to mention that over one in four providers report that these prior authorization requests often or always end up being denied.   These experiences with traditional prior authorization methods have severe consequences for healthcare providers. They lead to increased physician workload, burnout, and lost time and productivity.  For patients, the time required to process manual paperwork can be a frustrating roadblock to accessing timely care. A convoluted prior authorization process also adds extra hurdles to working with different healthcare specialists for patients with multiple chronic conditions. Consequently, processing prior authorizations through traditional methods could lead to delays in care and even treatment abandonment.   The impact on patient outcomes is also quite significant. According to the AMA, more than nine out of 10 doctors report negative effects due to prior authorizations.   Additionally, payer policies are constantly changing, compounding this issue. It's hard for providers to stay up-to-date and ensure submissions are accurate. These new changes are often unannounced, making it more likely for healthcare providers to make prior authorization requests based on outdated rules. As a result, many of these submissions are instantly rejected.   Challenges with traditional prior methods point to one fact: the need for a more efficient prior authorization system is evident and urgent.  Why healthcare providers should use electronic prior authorizations  Electronic prior authorization entails systems or solutions that streamline the process of obtaining approval for proposed medical procedures, services and medications to be delivered. These systems enable healthcare providers to initiate authorization requests electronically, eliminating the need for manual paperwork processing. They are designed to improve operational efficiency, reduce healthcare providers' administrative burden and ensure patients receive care as early as prescribed.   Alicia Pickett, Senior Product Manager at Experian Health, says, "As healthcare providers face increasing administrative demands, automating prior authorizations is no longer just an efficiency measure—it's a necessity. By streamlining this process, we enable providers to focus on what matters most: delivering timely, high-quality care to their patients."  Overall, electronic prior authorizations connect payers' objective of only remunerating high-quality, appropriate and cost-effective care and providers' aspiration to bypass excessive procedural prerequisites for reimbursement. They also help ensure patients enjoy seamless and timely healthcare encounters that culminate in favorable clinical outcomes.  The benefits of electronic prior authorization solutions  The traditional prior authorization workflow can be tedious, time-consuming and error-prone. Enter electronic prior authorizations. Its unique capabilities offer many advantages for hospitals, healthcare providers and patients.  Neeraj Joshi, Product Director at Experian Health, says, "The true value of electronic prior authorizations lies in its ability to remove barriers to care. By reducing approval times and minimizing paperwork, patients receive faster access to the treatments they need, ultimately leading to better outcomes and fewer delays in critical care."   Here are some benefits of using electronic solutions to address prior authorization hurdles.  Reduced administrative burden  Prior authorization can be lengthy and frustrating when healthcare providers have to gather, review and complete hundreds of pieces of paperwork weekly. Electronic prior authorizations accurately and efficiently take care of these burdens in a way that human efforts cannot replicate.   Improved operational efficiency  Electronic solutions for prior authorizations are a partner tool that helps hospital management allocate resources appropriately. They can also help reduce staff workload and workflow, even amidst staff shortages. By freeing healthcare providers and staff from the time-consuming task of handling prior authorization paperwork, they can focus more on enhancing patient experience, care and satisfaction. As a result, hospitals have a more productive, less stressed and efficient workforce.  Reduced claim denials  Errors in the prior authorization process are a leading cause of claim denials, particularly when hospitals use traditional methods. Electronic authorizations help reduce the risk of claim denials by ensuring accuracy and completeness at every step of the submission process.   Improved patient experience and outcomes  Traditional prior authorization methods lead to costly care delays and frustrating patient encounters with the healthcare system. On the other hand, electronic accelerates time to care delivery, reducing the likelihood of patients experiencing adverse effects.  Increased hospital financial resources  By automating the prior authorization stage, healthcare organizations can speed up the entire claims and revenue management process. This accelerated system also helps reduce claim denial rates and boosts reimbursement rates. As a result, cash flow improves, ultimately strengthening their financial standing.  Key features of prior authorization software  Experian Health's prior authorization software, Authorizations, is an integrated online service that automates the inquiry and facilitates the submission processes for prior authorizations. The system automatically fills in payer information, and users are only infrequently prompted to make inputs.  Key features of the prior authorization software include:  Knowledgebase: Authorizations can access real-time and up-to-date prior authorization requirements and criteria in the National Payer Rulesets.   Submissions support: The software guides users to the appropriate website and presents patient data in an efficient format so that users can create clean submissions.  Enhanced workflow: It works with dynamic work queues, which provide an instant view of the prior authorization status and guide users through any pending tasks.  Postback: Users can send information about authorization status to the health information system (HIS) and practice management systems (PMS).  Image storage: Images of payer responses can be received and stored securely in the software's integrated document imaging system.  Reconciliation: The software offers insights into and helps resolve authorization variances, allowing staff to take proactive steps to prevent denials and appeals.   Electronic prior authorization solutions are a valuable time- and resource-saving investment for stakeholders in hospital revenue management. According to the Council for Affordable Quality Healthcare (CAQH), the healthcare industry could save around $494 million annually by using them. In addition, providers can save 11 minutes per prior authorization transaction with electronic solutions.  Additionally, electronic prior authorization software creates a win-win situation for healthcare providers and payers: Payers only release payments when necessary and hospitals get steady, adequate cash flow to meet the operational expenses of delivering quality care.   Find out how Experian Health's electronic prior authorization software, Authorizations, helps healthcare organizations achieve faster reimbursement rates.  Learn more Contact us

Reimbursement issues in the healthcare industry are complex, but reimbursement is essential for healthcare organizations. Proper reimbursement allows providers to run operations efficiently and deliver consistent, high-quality patient care. It also enables organizations to invest in technologies that advance their operations. Read on to learn more about the causes of reimbursement issues and discover the strategies, tools and automated solutions healthcare providers can use to address them. Understanding reimbursement issues in healthcare Healthcare organizations often provide care without upfront payment and hope that healthcare payers will fulfill their obligations and settle their bills. This system impacts all healthcare stakeholders and influences the quality and timeliness of patient care. It also affects staff productivity, satisfaction, hospital operational efficiency, cash flow and bottom line. However, the reimbursement system is also fraught with long-standing challenges that complicate financial growth for healthcare organizations. Claim denials, changing reimbursement landscape and payer rules, prior authorization hurdles and staffing shortages complicate reimbursement issues in healthcare and cost hospitals billions of dollars in administrative complexities. Key challenges of healthcare reimbursement concepts Key challenges that fuel reimbursement issues and impact hospital cash flow include: High patient volumes and submission of inaccurate claims Complex payer policies, compliance issues and poor communication in payer-provider partnerships Increasing claims denials leading to nonpayment Staff shortages and lack of training Slow adoption of data, analytics and automation solutions Causes of reimbursement issues By identifying the causes of reimbursement issues that result in delays and nonpayments, healthcare organizations can develop effective strategies to tackle them. Here is a closer look at why reimbursement issues commonly occur: Rising claim denials Claim denials lead to delayed or lost reimbursements, which amount to millions of dollars in lost revenue for hospitals. The Journal of AHIMA reports that claim denials cost hospitals $5 million, annually. According to Experian Health's State of Claims report, 38% of healthcare providers experience claims being denied 10% of the time, or more. 67% of respondents also agreed that reimbursement times are increasing. A report from the American Hospital Association noted that Medicare Advantage plan payment denials increased by 56% for the average health system between January 2022 and June 2023. These denials led to a 28% decline in cash reserves—even as maintenance expenses rose by 90% and other operational costs increased by up to 35%. With increasing claim denials, rising operational costs and a drop in cash reserves, revenue cycle leaders are under pressure to address costly claim denials. Staffing shortages and lack of appropriate training Challenges with staffing shortages and inadequately trained staff to handle revenue cycle management processes can lead to reimbursement issues for healthcare organizations. New research, published daily, shows that healthcare organizations are grappling with staffing shortages and the associated consequences. Experian Health's recent survey, Short Staffed for the Long-Term, identified staffing shortages as being strongly linked with increasing claims denial and declining reimbursement rates in healthcare. In fact, nearly all survey respondents noted that staff shortages have affected their organization's revenue opportunities. According to 70% of the survey respondents, staff shortages are seriously impeding payer reimbursement, and 83% report that it has become increasingly challenging to follow up on late payments or provide assistance to patients facing financial difficulties. In another Experian Health survey, The State of Patient Access, 2023: The Digital Front Door, 87% of providers report that healthcare staffing shortages are worsening healthcare access. Additionally, inadequate and lack of up-to-date training in handling medical coding, eligibility verification, patient estimates and other necessary administrative processes for preparing and submitting clean claims and receiving reimbursement hamper the efficiency of existing staff. Complex prior authorization process When healthcare organizations fail to obtain prior authorization in cases where it is needed, they can inadvertently face healthcare reimbursement issues. Prior authorization is a cost-control mechanism used by payers to confirm the justification for costly healthcare services. When prior authorization is required, providers must receive approval from payers before their services can be eligible for reimbursement. Prior authorization is a heavy and time-consuming administrative burden. According to the 2023 AMA prior authorization survey, every healthcare physician completes 43 prior authorizations per week on average—a process that takes about 12 hours. Worse, more than a quarter of providers report that prior authorizations are often or always denied. The complex prior authorization process leads to treatment delays, abandonment and reimbursement hassles. Many denials occur after patients have already started receiving care, or or when required care is only partially covered, causing further challenges. Changing reimbursement policies and payer rules Healthcare providers unintentionally fall behind in staying updated on critical reimbursement policies. The reasons vary, but typically include shifts in the reimbursement landscape, inconsistencies in payer rules, unannounced rule changes and poor communication in payer-provider relationships. Complex and ever-evolving payer policies also result in substantial losses for hospitals. Hospital revenue and resources, staff productivity and satisfaction and patient experience all bear the brunt. Hospitals relying on manual processes instead of automated software solutions to manage reimbursement hurdles are often hit even harder. Strategies to resolve healthcare reimbursement issues Organizations working to achieve impactful reimbursements can adopt strategies for success, including: Adopt AI and automation to prevent claim denials In the State of Claims 2024 report, only 31% of providers reported using some form of automation and/or AI technology. Automated solutions provide a time-and-resource-efficient approach for healthcare organizations to streamline claims and revenue cycle management. For example, ClaimSource® is a single software solution used to automate the claims management process and improve reimbursement rates. This solution automates tasks crucial to claims approval and reimbursements, like eligibility verification and coding, making the process faster and error-free. Experian Health's AI Advantage™ is a prime example of an AI-powered solution that works seamlessly with automation solutions to provide organizations with the greatest potential for reimbursement. It offers a two-in-one avenue relevant before claims submission and after claims denial. Organizations can reduce denial rates with Predictive Denials and predict high-value denials that improve reimbursement rates with Denials Triage. Implementing AI and automation can help strengthen financial performance and increase reimbursement rates for healthcare organizations. When integrated with AI-powered solutions that provide prediction and accuracy, automation takes the claims management burden off the shoulders of overworked staff. Staff can then redirect their efforts towards activities that enhance patient experience, care quality and outcomes. Automate prior authorizations Prior authorizations can be time-consuming and expensive, especially with manual, error-prone systems. According to a paper published in the Journal of Perspectives in Health Information Management, 85% of providers consider the burden associated with prior authorization to be “high or extremely high.” Yet, many providers still rely on manual processes, which further complicate prior authorizations and create stumbling blocks to getting reimbursements. Instead, healthcare organizations can embrace automated solutions, like Experian Health's Prior Authorizations solution, to streamline this process. This solution automates the prior authorization inquiry and submission process and helps providers achieve prompt payments, ultimately ensuring predictable revenue cycles. By adopting automation, they save staff time and improve operational efficiency, which also improves care delivery and elevates the patient care experience. Equip staff with technology solutions Healthcare billing teams can also effectively tackle critical aspects that increase the potential of securing reimbursements using technology solutions designed to help boost productivity without increasing headcount. These include: Denial Workflow Manager to eliminate the need for manual review of claims status and remittance advice, resulting in reduced denials Enhanced Claim Status eliminates manual follow-up tasks and lets providers respond early and accurately to pended, returned-to-provider, denied, or zero-pay transactions before the Electronic Remittance Advice and Explanation of Benefits are processed Patient Payment Estimates to provide better price transparency so patients are empowered to make better decisions and healthcare providers get paid faster Overcoming reimbursement issues for better healthcare outcomes Reimbursement issues pose many challenges for today's healthcare organizations. They burden hospitals with excessive administrative work, cause delays in healthcare delivery and put the patient experience in the backseat. They also impact healthcare provider satisfaction and productivity and worsen hospital financial performance. Empowering staff with automated solutions enables them to swiftly and accurately manage the different fragments leading to reimbursement. This can result in improved healthcare outcomes and organizational profitability. Learn more about how Experian Health's Claims Management and Clearinghouse solutions (ranked #1 Best in KLAS 2024) can help organizations secure reimbursements that boost their bottom lines. Get reimbursed faster Contact us