All posts by kelly.nguyen

Challenge The University of Tennessee Medical Center (UT Medical Center) is a leading 710-bed acute care hospital with a rich history of exceptional patient care and award-winning services. During the pandemic, the hospital faced revenue losses around $45 million that put serious strain on its capacity to invest in bigger and better facilities. UT Medical Center needed to find a strategy to recover some of this revenue by reducing claim denials at the point of patient registration. UT Medical Center relied on eligibility checks that often missed errors in patient registration, resulting in increased claims denials, costly reworks, and wasted staff time. The hospital urgently needed a solution to help staff identify and resolve potential patient registration errors in real time to prevent denials before they occur. Finding a more efficient way to capture accurate patient and benefits data would be essential. Proactively preventing claim denials would provide the hospital with the much-needed boost in cash collections it needed and free up staff to focus on patient care. Solution To address its claims denials challenge, UT Medical Center partnered with Experian Health and implemented Registration QA, a solution designed to find and fix registration errors upfront. Now, when patients first arrive, front-end staff enter their data to verify insurance. If Registration QA finds an error, it alerts staff in real time so they can resolve it within 72 hours. Alongside more than 400 alert rules curated by Experian Health, UT Medical Center also built custom alerts based on the organization’s specific requirements, using demographics and benefits data. Learn more

Experian Health is very pleased to announce that we've ranked #1 in the 2025 Best in KLAS: Software & Services report, for our Contract Manager and Contract Analysis product, for the third consecutive year. Contract Manager, when paired with Contract Analysis, empowers healthcare providers by ensuring payers comply with contract terms, identifying and recovering underpayments, and arming them with real claims data to negotiate contracts. This enables providers to negotiate more favorable terms and maintain financial stability.  Clarissa Riggins, Chief Product Officer at Experian Health, says, “In the ever-evolving healthcare landscape, our Contract Manager solution has once again been recognized as the #1 Revenue Cycle Management tool by KLAS for the third consecutive year. This prestigious ranking underscores the significant value our solution delivers to our clients by identifying underpayments and facilitating revenue recovery. We are honored to continue supporting our clients with innovative solutions that drive financial success and operational efficiency.”  Learn more about how Contract Manager and Contract Analysis can help your healthcare organization validate reimbursement accuracy, recover underpayments and boost revenue.   Learn more Contact us

Patient engagement still has a long way to go, and hinges on patient access. According to the 2024 Experian State of Patient Access survey, just 28% of patients feel access has improved since the previous years. However, more than half (51%) feel it has remained static. Today's patients are tech-savvy and have access to more health information than ever before. They want to be more active in their care, from scheduling appointments to messaging providers directly with their questions and concerns. Experian Health data also reports that 60% of patients are looking for more digital and mobile options to better engage with providers. Around the same percentage say they'd consider switching providers in order to get the access they crave. In 2025, healthcare organizations must empower patients with the control they want and an overall positive patient experience. Providers that successfully give patients a voice and opportunities to play an active role in their care are more likely to retain patients, see better health outcomes and keep revenue cycles in check. Here's a closer look at how providers can increase patient engagement, why it matters and key strategies that deliver improved end-to-end patient experiences. What is patient engagement? Patient engagement is a proven strategy healthcare providers have relied on for decades to improve patient care, boost outcomes, increase retention and keep revenue cycles churning. This patient-centric care approach encourages patients to take an active role in all aspects of their treatment – from decision-making to self-management. When successfully implemented, patient engagement gives patients autonomy over their personal wellness journey and forms a trusted and often lasting partnership between patients and providers. Why is patient engagement critical for healthcare providers? Engaged patients are informed patients who stay on top of their overall health and wellness. They're also more likely to identify symptoms sooner, attend appointments, follow aftercare instructions and have better health outcomes. When patients are actively involved in their care, they have a more positive patient experience, which increases patient satisfaction, preventative care, retention and repeat visits. The healthcare landscape continues to evolve rapidly. Today's patients have more choices and access to care than ever before. Thanks to an onslaught of emerging digital providers and big-name retailers now offering healthcare services, patients can see a provider without leaving their homes, or pop in for a care visit while shopping for groceries. Patients want to see their doctor quickly and crave the convenience of user-friendly digital tools to book appointments, complete intake paperwork and keep tabs on their care. To meet growing patient needs and keep pace with industry shifts, healthcare providers must adopt the latest strategies and technologies and increase patient engagement, or risk losing patients (and revenue) to providers that deliver more tech-savvy and personalized experiences. Challenges in patient engagement Improved patient engagement is a top priority for both patients and healthcare organizations. However, the industry faces several key hurdles to elevating the patient experience. Lack of patient access The patient-provider relationship starts with prompt access to an appointment. Patients prioritize being able to see their providers quickly and often measure their entire patient experience on the ability to get on the schedule. Experian Health's State of Patient Access survey data shows that opinions on appointment access hinge on wait times. In fact, both patients who think patient access has improved and those who think access has worsened cite wait times as their reason. However, patients don't just want to be seen sooner; they want more self-service options to be in control of their appointments. Nine out of ten patients want to schedule appointments online or with a mobile device—anytime, anywhere. Nearly 90% of today's patients prefer to avoid tedious intake paperwork and would welcome a digital or paperless pre-registration experience. Outdated systems and technology Healthcare providers have been increasingly adopting new technology solutions, like online patient portals and telehealth, since COVID-19 kicked off major industry changes. However, the healthcare ecosystem is still heavily weighed down by complicated, outdated systems. For instance, nearly 60% of providers still use at least two different tools to gather the necessary patient information for claim submission. These manual (and often disjointed) processes can frustrate patients, burden staff, and affect all stages of the patient health journey and revenue cycle. Patients want easier access. Experian Health data reports that 60% of patients say they want more digital tools to manage their healthcare. Providers that want to improve the patient experience and stay relevant with patients must consider investing in user-friendly technology that meets the demands of today's tech-savvy patients. Staffing shortages expected to continue Unfortunately, one of the biggest challenges in the healthcare industry isn't showing signs of letting up any time soon. The American Hospital Association (AMA) reports that by 2028, the healthcare industry will experience a shortage of approximately 100,000 critical workers. With these expected shortages, already strained staff may struggle to keep up with administrative tasks that directly affect patient care. Without a solution to streamline tedious admin work, bottlenecks are likely to continue across scheduling, registration, insurance eligibility checks, claims processing, collections and follow-up communications. Strategies to increase patient engagement in healthcare The pandemic brought many advances to the healthcare industry, including virtual care and telehealth. However, today's patients want even more access. Digital tools that offer a seamless patient engagement experience, like patient portals, mobile registration and online scheduling, can help providers keep patients engaged and improve satisfaction. Healthcare organizations can benefit by adopting some of the following strategies to increase patient engagement and, ultimately, patient outcomes and revenue.  1. Implement patient self-service options Embracing user-friendly technology that opens the digital front door is critical to elevating the patient experience at every stage of the health journey. With the right technology solutions in place, healthcare providers can meet patients' growing demand for digital tools and improved access while easing administrative burdens on staff. It's no wonder nearly 80% of providers report planning to invest in patient access improvements soon. Automated patient intake solutions that kick off the registration process, like Experian Health's Registration Accelerator, engage patients early, right from their mobile devices. Patients have the flexibility to complete intake paperwork on their own time, while providers can verify patient details quickly, without tedious manual processes. Case study: How West Tennessee Healthcare simplified registration with Registration Accelerator. 2. Streamline patient and provider communication Communication is a key part of creating a positive patient experience. It starts with the first impression a provider makes during the initial contact – well before the patient even steps foot in the door. Online appointment booking options offer patients the 24/7 self-service scheduling they crave. Tools like Experian Health's patient scheduling software guides patients to the appropriate provider and appointment while keeping the provider in control of their calendar. Patients receive text reminders and can cancel or change their appointments as needed. Other self-service options, like online patient portals, make it easy for patients to have visibility into their care and communicate with providers directly. Patient outreach solutions can also close the gap between patient and provider communications, by enabling patients to conveniently self-schedule via SMS or IVR campaigns. Providers can also engage patients with automated, timely messages and meet patients where they are. On-demand webinar: See how IU Health increased one-call resolutions with Patient Schedule 3. Create personalized financial plans for patients With healthcare expenses on the rise, patients want to know how much care will cost before they receive treatment. More than 80% of patients say pre-service estimates help them prepare for medical expenses; however, more than half report needing their provider's help to understand what insurance covers. Providers can improve the patient experience by offering accurate, upfront estimates and clear paths for patients to meet financial responsibilities. Tools like Experian Health's Patient Payment Estimates generate estimates of what a patient will owe, incorporating real-time pricing information, benefits and discounts. Providers can further streamline the patient's financial experience by implementing tools that help patients check if they qualify for financial assistance, receive payment plans and securely pay bills. Patients can be further empowered when providers offer a way to quickly pay bills from a secure link over text or a web-based app. Read more: How to maximize patient collections with digital technology Improve patient engagement with technology Technology continues to transform all aspects of healthcare and patient engagement. From creating customized treatment plans to improving patient outcomes, these new technology innovations are rapidly changing the face of healthcare. Tools like artificial intelligence (AI) and automation now play a critical role in helping providers streamline all aspects of revenue cycle management, including insurance eligibility checks, claims processing and collections. When providers invest in a wide range of patient engagement solutions, they can deliver a strong patient experience, improve patient engagement, reduce administrative burdens on staff and improve the bottom line. Find out more about how Experian Health's patient engagement solutions help healthcare organizations improve the patient experience at every stage of the patient journey. Patient Engagement solutions Contact us

As margins tighten, traditional revenue cycle management strategies are on shaky ground. Many healthcare providers are turning to automation and AI to simplify payments, prevent revenue loss and protect profits. This article breaks down some of the most common revenue cycle management (RCM) challenges facing healthcare leaders and offers a practical checklist to optimize patient access, collections and claims management, while building a resilient and patient-centered revenue cycle. Common challenges in revenue cycle management Revenue cycle management is how healthcare organizations handle the financial side of patient care, from patient billing to claims management. Healthcare providers rely on RCM to ensure they are properly paid, so they can keep the lights on, pay their staff and deliver quality patient care. Are traditional RCM strategies still fit for purpose? Consider some of the current challenges: Patients are responsible for a larger share of costs due to high-deductible health plans. How can providers help them understand their financial obligations and make it easier to pay without hurting their experience? Minimizing claim denials is a daily focus, thanks to constantly changing policies and regulatory updates. How do revenue cycle teams keep up with payers? Staffing shortages remain on the agenda. How can providers ease pressure on staff to maintain productivity and morale? There's also the question of how to turn mountains of data into actionable insights. How do teams interpret it correctly to identify bottlenecks and opportunities for improvement? Automation and AI offer a way through. When implemented thoughtfully, these tools can speed up processes, reduce errors and clear operational roadblocks for a more resilient revenue cycle. The following revenue cycle management checklist includes some of the key questions to consider along the way. Checklist for improving revenue cycle management Automating patient access Can patients book appointments online? Does the online scheduler automate business rules to guide patients to the right provider? Are patient identities verified at registration and point of service? A healthy revenue cycle starts with efficient patient access. According to the State of Patient Access 2024, 60% of patients want more digital options for scheduling appointments, managing bills and communicating with providers. Providers who see improvements in patient access also credit automation, which speeds up intake and improves accuracy. A good first step is to replace paper-based processes with online self-scheduling and self-service registration. These tools make life easier for patients, boosting satisfaction, retention and engagement. Behind the scenes, Experian Health's new AI-powered tool, Patient Access Curator, helps providers get paid faster by verifying and updating patient information with a single click – accelerating registration and paving the way for faster reimbursement. Register now: Exact Sciences and Trinity Health will share how Patient Access Curator is redefining patient access in this upcoming webinar. Optimize patient collections with data and analytics Are patient estimates provided upfront? Are notice of care requirements being addressed? Are patients offered appropriate financial plans and easy ways to pay? With more financial responsibility resting on patients' shoulders, patient collections are under the spotlight. The State of Patient Access report shows that upfront estimates and clarity about coverage are top priorities for patients, because when they know what they owe, they're more likely to pay on time. Implementing tools to promote price transparency and easy payment methods should feature in any RCM checklist. With Coverage Discovery, healthcare organizations can run checks across the entire revenue cycle to find billable commercial and government coverage that may have been forgotten, to maximize the chance of reimbursement. Meanwhile, Patient Payment Estimates offers patients clear, accessible estimates of their financial responsibility before treatment, so that hose who need financial assistance can be directed automatically to payment plans and charity options. Case study: How UCHealth secured $62M+ in insurance payments with Coverage Discovery® Improve claims management to reduce denials Are high-impact accounts prioritized? Are remittances reconciled with payments received? Does claims management software generate real-time insights and reports? With 73% of healthcare leaders agreeing that denial increased in 2024, and 67% saying it takes longer to get reimbursed, claims management is a great use case for automation. ClaimSource®, ranked Best in KLAS in 2024 for claims management, automates the entire claims cycle in a single application. It integrates national and local payer edits with custom provider edits to verify that each claim is properly coded before submission. By focusing on high-priority accounts, providers can target resources in the most effective way to ensure a higher first-pass payment rate. A major advantage for ClaimSource users is access to AI Advantage™. This tool utilizes AI to “learn” from an organization's historical claims data and trends in payer behavior to predict the probability of denial. It also segments denials so staff can prioritize those that are most likely to be reimbursed, reducing the time and cost of manual appeals and rework. Case study: After using AI Advantage for just six months, Schneck Medical Center reduced denials by an average of 4.6% each month, and cut rework time from 12 to 15 minutes per correction to under 5 minutes. Benefits of implementing a revenue cycle management checklist The key to choosing the right RCM tools and technologies is to build the strategy around what patients need most. A clear, transparent and compassionate billing experience is more manageable for patients and helps providers get paid faster. An RCM checklist helps teams stay focused on the tasks that matter. Providers can build on the suggestions above by choosing the key performance indicators (KPIs) that align with their specific goals. Metrics like financial performance, billing efficiency and collections rates can be combined to guide resource allocation, drive improvements and speed up reimbursement. With a well-designed checklist informed by clear KPIs, revenue cycle leaders can keep their teams on track and take their organizations from “surviving” to “thriving.” Learn more about how Experian Health's revenue cycle management tools can help healthcare providers meet current challenges, improve the patient experience and increase cash flow. Learn more Contact us

Prior authorizations continue to challenge healthcare organizations as payer authorization requirements expand and change. Automated prior authorizations can bring new efficiency and consistency to a process that's ripe for evolution, but how will providers make the leap? Alicia Pickett, Senior Product Manager at Experian Health, shares her perspectives on the issues providers are talking about now: How to speed up prior authorizations and deliver a better experience for users, leaders, physicians, and patients. Q: Why are providers increasingly concerned about prior authorizations? “Managing prior authorizations is complex,” Pickett says. “Providers have to deal with different payers, different standards, different service lines—all requiring different pieces of information. Without having all the right pieces in place, it's hard to drive a consistent workflow.  An inconsistent workflow can lead to denials, which can be very costly and affect patient care. “Once denials occur, managing them on the back end through appeals takes more time and additional personnel,” Pickett continues. “Creating a consistent workflow on the front end helps reduce manual work and decreases that denial rate.” Prior authorizations are in constant flux. A 2023 survey by the Medical Group Management Association (MGMA) found that 89% of medical practices find prior authorization requirements to be “very” or “extremely” burdensome. Of those surveyed, 92% hired additional staff and 97% reported patients experiencing delays or denials. The most common complaints were decision delays, obtaining authorization requirements for routine items or services, and inconsistent payer payment policies. Coping with complexity and change puts a strain on manual systems. “Inconsistent workflows leave room for interpretation and error,” Pickett notes. One user may be using sticky notes to record information they learned over the phone, while another coworker gets different information from the payer's website. “These coworkers aren't getting the benefit of each other's knowledge, and their information may not match,” says Pickett. “Given how frequently payers make changes, these inconsistencies can snowball really quickly.” Q: What are providers looking for to deal with prior authorization challenges? “Clients continue to look for more automation,” says Pickett. “They're looking for electronic prior authorization tools that help users work more efficiently and create consistency. For example, they may want tools to help determine which CPT codes require authorization and which ones don't. They may be interested in automated processes for follow-up. “Dynamic work queues, automated auth requirements, and follow-up allow users to spend less time on the phone and more time focusing on complex cases where electronic solutions are not available.” When training is time-intensive and staff is in demand, the benefits of automation go beyond administrative gains. “When users are more efficient, they're not only more effective; they're also happier in their jobs,” says Pickett. Q: How is client feedback shaping Experian Health's Authorizations product—and how is automation changing the way clients manage prior authorizations? “Here's an example. One of Experian Health's clients was able to move from a completely manual process, where they were printing schedules multiple times a day and handling inquiries by phone, to an automated prior authorization process using Experian Health's Authorizations solution. Now, they have automated work queues updated dynamically, in real-time. “The dynamic work queue allows users to know which accounts they're supposed to be working on, [even as] patients are being scheduled and rescheduled,” Pickett continues. “Knowledgebase allows users to spend less time on the phone or checking individual portals to find out whether CPT codes require authorizations.” In addition to creating more efficient workflows, Experian Health's Authorizations solution provides metrics organizations can use to evaluate and plan. “When providers use manual processes, leaders and managers aren't able to gather insights because there's nothing to tie metrics to,” Pickett explains. “This client was able to use insights from their electronic preauthorization processes to create greater consistency across their health system. They increased their throughput and managed the process more efficiently with a centralized team. When they were ready to support a new site, they used metrics to guide their planning conversations.” Q: What are the major drivers of change heading into 2025? “The CMS rule is going to be one of the biggest drivers of change,” says Pickett. The CMS final rule on prior authorizations was adopted in January 2024, with many provisions set to take effect in 2026. “What the rule states is that government payers—Medicare, Medicaid and others—are going to be required to provide information electronically through application programming interfaces, or APIs. Because of the CMS mandate, and because of the options that are available with expanding technology, we expect to see improvement in physician satisfaction and reduction in delays that impact patient care.” Pickett explains. These changes should benefit automation. “More data will be available on what requires an authorization, or on where an authorization stands,” says Pickett. “Automating messages reduces manual work and human error, and should make transactions more efficient.” Meanwhile, several states have created their own mandates. “State regulations provide transparency and require authorizations to turn around more quickly,” Pickett says. “They may help providers know what to expect, so they're not left guessing about when authorizations need to be adjudicated and when they'll be reviewed.” Security and privacy are additional concerns. “Recent security threats and breaches are also driving changes,” says Pickett. “Finding and mandating secure connections a key concern. Everyone wants to protect their patients' data, and rightly so." Q: How will electronic prior authorizations and other advancements impact the future of patient care? “Without question, creating greater consistency and efficiency will have a positive impact on patient care,” Pickett says. “Patients just want to know that they can get the service they need within the timeframe they're expecting without issues related to coverage or unexpected cost. A better authorization process provides patients with a better experience.” Physicians also benefit from improvements to the preauthorization process. “Knowing what to expect allows doctors to make informed decisions on how to proceed,” Pickett says. “When you have transparency, everyone is working together.” Finally, users can deliver a higher level of service when electronic processes are in place. “Expecting users to manage these complex processes on their own is a lot to ask,” says Pickett, noting that, with electronic prior authorizations, users are positioned to deal with heavy workflows and take advantage of new advancements on the horizon. “Automating prior authorizations is a big change, but the results can be transformational,” Pickett concludes. “As we continue to grow, physicians and revenue cycle leaders can focus on keeping their teams informed about what's happening, whether it's new payer connections, new information, or new technology,” Pickett says. “Staying informed helps users feel comfortable with the data that's coming back, so they can trust the process that's being automated.” Learn more about how Experian Health's electronic prior authorization software, Authorizations, uses automation to achieve greater consistency and efficiency for healthcare organizations. 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Nearly 46% of patients say being able to manage their health online is their top priority in accessing care, according to Experian Health's State of Patient Access 2024 survey (SOPA). However, the availability of a “digital front door” in healthcare – with online scheduling, mobile registration, and frictionless payments – is not yet meeting demand. Many patients still face convoluted booking systems and stacks of repetitive paperwork. Meanwhile, consumer-friendly tech and retail giants are edging into healthcare. As disruptors set new standards for simple and convenient care, traditional providers are under pressure to open their digital front door to remain competitive. Many are already investing in AI and automation to simplify workflows, cut costs, and upgrade the patient experience. Could 2025 be the tipping point for healthcare's digital transformation? A digital front door strategy could help more providers boost patient engagement, simplify the patient experience and increase profitability. What is a digital front door? The digital front door is more than a well-designed website. It's a single point of access that gives patients convenience, choice and control at every touchpoint in their healthcare journey. It promises patients faster appointments, fewer headaches and more coordinated care. From their mobile device or computer, they can log in to schedule visits, sign intake forms, update insurance details, see costs upfront and even settle their bills. It's secure, easy to use and lets patients handle tasks on their own time. On the back end, patient-facing digital tools can integrate into the provider's existing systems to improve workflows, reduce manual tasks and generate analytics to simplify care. What are the key benefits of implementing a digital front door? Patient satisfaction: According to SOPA, 60% of patients want more digital and mobile options for communicating with their provider, scheduling appointments and managing payments. Fewer no-shows: Patients are less likely to cancel or no-show when they can schedule and manage appointments that work for their time and needs. Frees up resources: Automating repetitive administrative activities means staff can focus on higher-value activities. Fewer errors: Manual processes are rife with data entry errors that increase the risk of denied medical claims and add time on the back end to resolve. Digital patient intake saves time and money by reducing opportunities for human error. Essential features of an effective digital front door What are some of the digital must-haves to simplify access to care? The checklist might include: Online appointment scheduling, to make it easy to book, reschedule, or cancel appointments Digital tools to complete pre-visit paperwork – even better if these automatically prepopulate patient info to save them time and reduce errors Transparent pricing, with tailored information delivered directly to the patient A choice of payment methods, including familiar digital options so patients can pay quickly Access to a patient portal or central hub for managing appointments, medical records and prescriptions Mobile-friendly interfaces and simple designs, so patients can see key data at a glance, from any device, without needing to be tech-literate Secure and compliant communications to protect patient data and privacy. Where to start with a patient-centric digital front door Three specific tools that would check off the above include the following: 1. Multi-channel patient scheduling What matters most to patients is being able to see their doctor quickly. Online appointment booking gives them the 24/7 self-service scheduling options they expect. It delivers quantifiable gains for providers too. For IU Health, automating patient scheduling has been shown to do the work of two full-time schedulers, with more than 35,000 appointments booked with self-scheduling. Experian Health's patient scheduling software guides patients to the appropriate provider and appointment while keeping the provider in control of their calendar. It integrates with a provider's website, call center, and physical office so patients can book their next appointment, even outside of office hours. On-demand webinar: See how IU Health increased one-call resolutions with Patient Schedule 2. Registration Accelerator 49% of providers say that a primary cause of denied medical claims can be traced back to errors in patient registration, forcing health systems to divert revenue to remediate claims that could have been avoided. An automated, data-driven patient registration process improves accuracy, making costly errors less likely. With Registration Accelerator, patients get a text when it's time to register, instead of completing forms in the waiting room. There's no need to download an app or create a user profile: they scan the data from their identity and insurance cards, and Registration Accelerator takes care of the rest. Anthony Myers, Director of Admitting and Registration at West Tennessee Healthcare, says that replacing clipboards with clicks also makes for a much better patient experience: “With our paper-based systems, it seemed like West Tennessee was stuck in the 1990s. We knew our patients expected a more modern experience. We wanted to meet them where they are, rather than forcing them to come to the registration desk. Our goal was to make pre-service registration easier and smoother for patients and staff.” Case study: How West Tennessee Healthcare simplified registration with Registration Accelerator. 3. Patient Financial Advisor The SOPA report shows that almost seven in ten providers believe their patients postpone care at least occasionally because they don't understand the cost of care. Eight in ten patients agree that accurate estimates help them prepare to pay. While price transparency is improving, too many patients still find themselves with bills that are higher than expected. Patient Financial Advisor delivers a pre-service estimate of the patient's financial responsibility based on real-time benefit information directly to their mobile device. It takes account of current provider pricing, payer contracted rates, and any relevant discounts or payment plans for greater accuracy. A secure payment link allows patients to settle their bills quickly and conveniently, at any time. Read more: How to maximize patient collections with digital technology Choosing the right partner for digital transformation Implementing a successful digital front door strategy comes down to one key factor: keeping it laser-focused on the patient. When choosing a vendor, providers should ask how the platform will make life easier for patients. Will it encourage proactive engagement? Is it easy to navigate and demonstrably secure? And on the back end, will it integrate smoothly with the provider's existing systems and workflows – and even improve them? The right partner will bring specialized expertise for a digital transformation, with the capabilities to meet both patients' and providers' needs. Find out how Experian Health's Patient Access solutions help healthcare providers open their digital front door to simplify patient care across the entire revenue cycle. Learn more Contact us

Patient eligibility verification is a critical part of the healthcare revenue cycle. It can help prevent errors with claim submissions, reduce denials, boost the bottom line, and help patients understand what their insurance will cover. However, checking insurance eligibility isn't always efficient or accurate, thanks to outdated systems and complicated manual processes. Ever-evolving payer requirements and new regulations, like the No Surprises Act, add even more complications during insurance eligibility checks. In 2024, providers also treated more patients than they did five years ago, making it harder to keep up with patient eligibility verification. This growing volume of patients have more complex health issues and may struggle to afford medical bills, putting a more pressing urgency on providers to run accurate eligibility checks before service. Having the right health insurance eligibility verification solution can make or break a provider's revenue cycle and allow staff to stay focused on patient care instead of digging for insurance information and correcting errors. This article takes a closer look at why patient eligibility matters, common challenges providers face and strategies to improve insurance eligibility checks, reduce payment delays and minimize denials. What is patient eligibility verification? Patient eligibility verification is an administrative process providers use to check whether or not patients have active medical insurance. It's typically completed before service occurs to confirm coverage for treatment and care. Sometimes called a health insurance lookup, the eligibility check verifies different aspects of a patient's coverage, including insurance status, coverage details and medical service benefits. During patient eligibility verification, billing information is also confirmed. Why is it critical for healthcare providers? Patient eligibility verification offers providers a first line of defense to protect revenue cycles against revenue leakage. It can help healthcare organizations with accurate billing, reduce claims denials and avoid footing the bill for uncompensated care. When eligibility checks are conducted diligently, providers see improved cash flow, staff efficiency is gained, the risk of bad debt is lower, and patients are empowered with accurate upfront estimates. The importance of patient eligibility verification Claim denial rates are growing and show no signs of slowing down. Experian Health's State of Claims 2024 survey reports that nearly three-quarters of respondents saw a rise in denials, with four in ten saying claims are denied 10% of the time. Eligibility issues, along with missing or inaccurate data, are a top reason for denials, according to 15% of providers surveyed. A reliable eligibility verification process is crucial to minimizing the claim denials, rework and billing errors that arise from inaccurate insurance information. It also lets patients know their financial responsibility upfront so there are no surprises when the bill comes. This trust and transparency fosters positive patient-provider relationships while ensuring patients get the care they need and providers get paid. Common challenges in patient eligibility verification Findings from Experian Health's State of Patient Access and State of Claims surveys point to several common challenges in patient eligibility verification. Evolving payer policies and pre-authorization requirements Insurance provider prior authorization requirements change often, making it hard for providers to keep pace. More than 75% of providers report an increasing amount of payer policy changes, and secondary eligibility checks take time and impact efficiency. When a necessary authorization is missed due to manual verification or rushed eligibility checks, it can result in denial, delayed payment and extra work – especially when care is urgent. Incomplete or outdated insurance information Insurance details in the provider's system don't always match the payer's record. This can happen for a wide range of reasons, including job switches, insurance plan changes or patients not being aware of or forgetting to mention secondary coverage. When these changes aren't caught before service, they can lead to rejected claims, billing delays and extra work for staff.  More than four in ten providers report adding at least 10 minutes of staff time per incomplete eligibility check. Inadequate technology to verify eligibility Staff must often wrangle a wide range of disjointed solutions, processes and logins during eligibility checks. While more than 70% of providers feel their organization runs insurance verification checks efficiently and accurately, nearly 60% of providers still use at least two different tools to gather the necessary patient information for claim submission. This can make navigating patient eligibility verification tedious and error-prone, and leads to staff burnout, denied claims and patient dissatisfaction. Strategies to improve patient eligibility verification In today's changing health insurance landscape, providers need to pay more attention than ever to their patient eligibility verification processes. Accurate and timely insurance verification streamlines the claims process, clarifies how bills will be covered (or not) ahead of time and helps patients prepare to pay their bills. Adopting the following strategies to improve patient eligibility verifications can help providers reduce the risk of denied claims, improve the revenue cycle and create positive patient experiences. Automate eligibility verification processes Verifying coverage early in the billing process increases the chance of submitting clean claims the first time. However, it can be tedious for providers to navigate outdated methods like online portals, file batching, automated systems and stay on top of ever-changing payer policies. Automated eligibility verification software helps providers optimize intricate insurance checks, access verified and comprehensive resources to confirm eligibility (with solutions like the MBI Lookup tool), and improve efficiency. Automatically track changing payer policy requirements With payer requirements undergoing constant updates, providers need to have access to solutions that keep up in real-time. Eligibility Verification, for example, seamlessly connects to more than 900 payers and features advanced patient matching tools. It can also be used with Experian Health's automated prior authorization tool, which tracks national payer requirements and flags providers when mandatory pre-authorization information is missing. Offer upfront, accurate cost estimates Patients want to know their financial responsibility up front. When armed with accurate estimates that help patients understand their coverage, co-pays and deductibles, more than 80% of patients say it helps them prepare financially. Eligibility tools allow providers to create more accurate estimates based on actual insurance coverage. This helps patients know what they're responsible for out-of-pocket and reduces surprise billing. Patient eligibility verification is more critical than ever in ensuring smooth and efficient revenue cycle management. With rising patient volumes, evolving regulations and other challenges impacting revenue cycles, providers need to maintain accurate insurance eligibility checks to reduce costly errors, streamline workflows and improve claims success rates. More importantly, accurate eligibility checks empower healthcare staff to focus on delivering quality care, while helping patients better understand and manage their financial responsibilities. Find out more about how Experian Health's insurance eligibility verification solution helps revenue cycle managers prioritize reimbursements with automated eligibility checks. Learn more Contact us

Medical excellence is a given when it comes to improving the patient experience, but what about the non-clinical side of care? Long waits, confusing processes and financial uncertainty can overshadow even the best medical treatment. As many as one in four patients delay care because of hidden administrative obstacles. As providers look to improve the patient experience in 2025, tackling these frustrations is top of mind. How easy is it for the patient to schedule their appointment? How quickly can they complete registration? Do they understand their insurance coverage, and do they have the right support to manage and pay their bills? Clear and straightforward patient access processes give patients support, convenience and control, and allow providers to focus on delivering care. This article looks at the challenges and opportunities that may affect patient access over the next year and highlights three ways to use digital tools to improve the patient experience. The patient experience in 2025: a rollercoaster of risks and opportunities Over the next year, patients' shifting needs and attitudes will change how they access care. Informed, tech-savvy patients armed with wearables and health-tracking apps want streamlined access and contact with their providers, and expect efficiency and personalization when they do seek care. At the same time, an aging population and increasing numbers of people with multiple chronic conditions drive demand for more complex and ongoing support. On the provider side, challenges like staffing shortages and remote work demands will continue to strain patient access teams. Payers' rapid adoption of artificial intelligence (AI) will continue to widen the denials gap. Rising costs will persist. Amidst this uncertainty, the forthcoming change of government may bring additional regulatory and legislative changes, so providers must be ready to adapt. Opening the digital front door is a way to elevate the patient experience to meet changing consumer expectations, while simplifying and streamlining processes so they can respond to whatever's in store. How can digital tools help improve the patient experience? Digital tools take the patient journey from a series of disjointed encounters to a coordinated and personalized experience. Building on innovations that gained momentum during COVID-19, like telehealth and virtual care, these tools keep patients and providers connected throughout the care process. By tailoring experiences to individual needs in real time, digital tools integrate into daily life and meet the rising demand for convenient, tech-driven options. Three ways to improve the patient experience Experian Health's latest State of Patient Access survey offers some pointers as to what providers should prioritize: 1. Expedite scheduling so patients can see their practitioner quickly Patients measure the patient experience by how quickly they can see their doctor. In the State of Patient Access survey, both those who think patient access has improved and those who think it has worsened give this as their reason. As patients' top priority, efficient scheduling is an obvious focus for providers who want to improve the patient experience. Online scheduling, mobile registration and self-service portals can simplify how patients book and check in for appointments. Patient Schedule lets patients book appointments anytime they like without needing to call. It only offers specific types of appointments with the right provider and makes it easy to cancel and reschedule, so no-shows are less likely. This also increases providers' capacity, giving patients more options so they can see their doctor sooner. Mobile registration complements digital scheduling by allowing patients to complete registration forms anytime, anywhere. Automated registration prefills information held on file to minimize paperwork, which is good news for the 85% of patients who do not want to fill out paperwork if they've already provided the information. Reducing manual errors also reduces delays so that patients can get on with their visit. 2. Help patients understand their insurance coverage and bills Patients and providers both cite financial challenges among their top priorities for improving patient access. More than eight in ten patients say pre-service price estimates help them prepare for the cost of care, while more than half say they need their provider's help to understand what their insurance covers. Providers should consider digital tools that support transparent pricing and billing to improve patients' financial experiences. Experian Health's Patient Payment Estimates generates accurate, upfront estimates of what a patient will owe, incorporating real-time pricing information, benefits and discounts. Estimates and secure payment links can be sent to patients via text or through the web-based app for a convenient and user-friendly payment experience. Additional tools can help patients find missing coverage and identify suitable payment plans, empowering patients and accelerating collections for providers. 3. Explore how automation and AI can support a better patient experience The growing use of AI will continue to reshape all aspects of care. By processing vast amounts of information at an unprecedented rate, AI presents exciting opportunities in patient access: keeping patients informed, generating performance insights and reducing the errors, delays and bottlenecks that come with manual processes. One of the highest-ranking challenges for providers in the State of Patient Access survey was the difficulty of managing multiple solutions to run patient eligibility and coverage checks. Patient Access Curator uses AI to address this with a single-click solution that captures all patient data at registration. It checks and verifies eligibility, Medicare Beneficiary Identifiers, coordination of benefits and demographics, delivering results in just 30 seconds. This prevents denials on the front end and takes the pain out of registration and scheduling for patients. Read the blog: How Patient Access Curator uses real-time, automated discovery to prevent denials and improve patient access Put patients in the driver's seat in 2025 As competition intensifies with new providers and disruptive technologies entering the market, patient satisfaction will no longer be optional — it will define success in 2025. Investing in digital patient access tools gives patients the autonomy, choice and convenience they crave as modern digital consumers. Simplifying and streamlining access will not only help meet and exceed patient expectations, but will help providers future-proof their operations and build a sustainable revenue cycle for the years ahead. Find out more about how Experian Health's patient engagement solutions will help providers improve the patient experience in 2025. Patient Engagement solutions Contact us

The growing shift from inpatient to outpatient care continues. The U.S. ambulatory services market was estimated at USD 289.5 billion in 2023 and is projected to grow at a CAGR of 5.38% from 2024 to 2030. A Deloitte study notes that the gap between inpatient and outpatient revenue has been closing for two decades. But what's driving this boom? Clinical advances, patient demand for lower-risk and lower-cost options and payer pressure all play a role. New technologies, like advances in orthopedics, allow more procedures to be performed at outpatient service centers instead of costly hospital settings. Free-standing ambulatory surgery sites are expected to see a 14% volume boost over the next decade as more service lines, like cardiovascular and neurosciences, begin to shift procedures from inpatient to outpatient facilities. The ongoing growth in outpatient services presents a unique opportunity for revenue cycle leaders to use technology to improve outpatient revenue—and the overall patient experience. Grow outpatient revenue with more digital care Patients want a better experience at every step of the patient journey. They want to see their doctor faster, manage appointments online and understand how much it costs—with as little red tape as possible. A lack of streamlined patient access and transparency often results in no-shows, a rise in claims denials, wasted staff time and patient complaints. However, by opening the digital front door, providers can give patients the self-service tools they crave, improve the care experience, keep outpatient schedules full and increase revenue. Additionally, providers can use technology like artificial intelligence (AI) to lower claim denial rates. Here are five strategies to increase outpatient revenue in 2025. 1. Make patient access simple Patients want to see their doctor faster. In Experian Health's latest State of Patient Access survey, eight in ten patients who reported being unhappy with their provider experience cited waiting for an appointment as a top complaint. When trying to schedule, patients are also frustrated by the friction that comes with complex processes, clunky technology systems and sparse provider communication. Outdated manual workflows, staffing shortages and lack of staff training often result in challenges for both patients and providers. Improved patient access is at the heart of patient-centered healthcare. Technology designed to put the patient in control, like online patient scheduling and digital patient intake tools, offer continuous patient engagement, optimized scheduling, and streamlined administrative processes. By leveraging modern patient access solutions, providers can improve patient experiences and alleviate the impact of staffing shortages. 2. Reduce appointment no-shows Missed appointments cause headaches for patients, providers, and revenue cycle managers. Online scheduling and mobile registration are also top of mind for patients. In Experian Health's State of Patient Access 2024 survey, 89% of patients said they wanted self-service scheduling and 85% reported a dislike for filling out repetitive intake paperwork. Online patient scheduling software puts patients in the driver's seat, providing convenient and secure 24/7 access to book, reschedule, and cancel appointments on their own time. Solutions like Patient Schedule sync seamlessly to an organization's scheduling rules, and patients receive automated appointment reminders by text or IVR. On average, providers that use Experian Health's scheduling solution experience an 89% show rate, a 50% reduction in scheduling time, and a 32% increase in patients per month. Patient intake tools like Registration Accelerator simplify mobile registration with a streamlined text-to-mobile experience. Once registration is complete, automated returns of forms, patient-check-ins and demographic information ease the burden on staff. 3. Help patients prepare for outpatient costs Patients need a clear breakdown of their financial responsibility before receiving care. Without it, they may be unable to prepare for care costs appropriately. While hospitals are now required to share detailed pricing for at least 300 common procedures, confusion around a patient's actual financial responsibility still persists. More than half of patients report turning to their provider for help understanding what insurance covers. Digital solutions that provide accurate, upfront estimates empower patients. More than eight in ten patients say pre-service estimates help them prepare for the cost of care. Patient Payment Estimates provide upfront, real-time estimates of what a patient will owe. Providers can offer convenient and secure payment links, and allow patients to pay their bills online or see customized payment plans. Outpatient providers can further maximize the chance of reimbursement by running health insurance coverage checks across the entire revenue cycle. This can help find billable coverage that may have been forgotten and give patients greater certainty about what they'll owe. 4. Automate healthcare collections Collections are often a major challenge in the outpatient revenue cycle. Outpatient procedures can be costly, even with insurance, leaving patients responsible for potentially large bills. Automating healthcare collections allows for faster, more efficient, and more compassionate collections. Tools like Collections Optimization Manager helped Novant Health achieve an overall recovery rate of 6.5% and increase revenue and cost savings to a rolling average return on investment of 8.5:1. With automated tools like Patient Financial Clearance, providers can assess patients' ability to pay and assign them to an appropriate financial pathway. This allows patients to quickly get the assistance they need while freeing up valuable staff time. 5. Streamline claims to increase outpatient revenue Denied claims continue to be problematic for providers. In Experian Health's State of Claims 2024 report, which surveyed 210 healthcare revenue cycle leaders, nearly three-quarters of providers feel claims denials are increasing, while 67% feel getting paid is taking longer. Claims management software can help end the cycle of denials. However, around half of providers still use a manual claims review process, and only 28% feel confident in their understanding of automation, machine learning and AI. Adopting automated and integrated healthcare claims management solutions can reduce errors, prevent undercharges, and ensure a higher first-pass payment rate. Tools like Experian Health's ClaimsSource® simplify the entire claims process, while Claim Scrubber helps providers submit more accurate claims. Digital solutions can also automate claim status monitoring and eliminate manual denial processes. Implementing AI tools to interpret past claims data and recommend next steps can improve outpatient claim denial statistics. Tools like AI AdvantageTM look at past payer behavior and historical claims data to predict and prevent denials. AI Advantage's two components, Predict Denials and Denial Triage, help providers respond to growing denial challenges by identifying claims with a high likelihood of denial before submission, and focus on remits that have the most impact. See how: Find out more about how Experian Health's revenue cycle management solutions can help healthcare organizations increase outpatient revenue, keep pace with growing patient volumes, improve patient satisfaction and boost their bottom lines. Learn more Contact us