Claims & Contract Management

Medical billing is the first line of defense against claims denials. However, medical billing errors cost U.S. healthcare systems approximately $935 million weekly. Not only do preventable errors wreak havoc on providers' revenue cycle, but patients say they're frustrated at the time spent correcting these errors—45% spend up to one month on the back and forth between payers and provider billing teams. Better medical billing software can automate claims management at the beginning of the reimbursement process and eliminate the traditionally labor-intensive processes plagued by human errors. Medical billing software can also make it easier for patients to pay and understand their coverage eligibility for fewer surprises after their care encounter. This article discusses how healthcare providers can implement these tools and set the stage for a better revenue cycle, happier patients, and more efficient care delivery. Common problems with medical billing Experian Health's State of Claims 2022 report showed healthcare denials increasing substantially each year. Some of the most common medical billing errors include: Medical coding transforms a healthcare service deliverable into reimbursable revenue. Yet Experian Health data shows that 42% of providers say inaccuracies in coding reporting lead to frequent claims denials. Coding errors delay reimbursement and, at worst, increase the risk of health system fraud, abuse fines, or even impact patient care with an incorrect diagnostic code. Patient information errors, including missing or incomplete prior authorizations, are among the top three reasons for claim denials. Even a misspelled name or date of birth can cause the claim to return to the provider for correction. Problems with outdated medical records and manual data entry exacerbate these issues. While each provider and payer has unique claims denial numbers to share, Medicare reports that the average volume of errors is just over 7%. Yet providers can't take all the blame for the volume of clerical errors given the complexities of ICD-10 requirements. Medical Economics explains, “The Centers for Medicare and Medicaid Services (CMS) announced 395 new diagnosis codes, 25 deletions and 13 revisions for the fiscal year (FY) 2024 ICD-10 CM code set.” Medical billing software is critical for preventing healthcare claims denials by keeping up with these complexities and avoiding human errors. What can the latest round of automated, artificial intelligence (AI) powered software do for the average healthcare provider? Prevent claims denials with better medical billing software Experian Health's Patient Access Curator solution heads off claims denials before they happen. The solution incorporates AI to improve the accuracy of claims management at patient registration and billing. The system leverages logic that returns multiple data points from a single inquiry in 30 seconds - streamlining benefits coordination, lessening patient identifier errors, and spotting “hidden” eligibility. Some of the benefits include: Faster and more accurate eligibility verification - Legacy medical billing software operates from a clearinghouse model. However, these tools often miss active, billable coverage and require extensive manual workflows to edit claims and appeals. AI eliminates the standard by-hand workarounds correlated with traditional billing software. Better coordination of benefits (COB) - COB denials are common in healthcare. Many patients do not understand the intricacies of government and commercial coverages and how they interact. Patient Access Curator can help. When integrated into the registration eligibility verification process, this AI-powered tool can lessen or eliminate COB denials by identifying hidden payer coverage requirements that outdated software cannot find. Additionally, the software can trigger automatic inquiries to third parties to verify active coverage quickly. Streamlines MBI conversions - How much time do providers spend tracking down Medicare Beneficiary Identifiers during patient registration? The complicating factor is that MBIs change without warning; many patients and providers find out after the payor rejects the claim. Providers can eliminate this frustration by adding software that automatically updates MBIs in real-time. No more searching websites, calling patients—or reworking the claim. Increases accuracy of patient demographic data - The quality of healthcare data can begin to erode at registration. Incorrect or obsolete patient data is a challenge for the entire industry. It makes sense that up-to-date, accurate patient demographic information improves their experience. Providers can eliminate obsolete or incorrect patient data with better medical billing software to lessen claims denials. Patient Access Curator automatically updates outdated information for cleaner claims and more accurate data. Automates coverage and financial verification for increased accuracy - Patients and providers benefit from AI automation that accurately identifies payment details. The solution is particularly beneficial for spotting missed revenue opportunities for self-pay, unbillable, or patients with unspecified payer status records. Patient Access Curator also identifies each customer's ability and propensity to pay, increasing the likelihood of successful revenue capture later while maintaining patient satisfaction and comfort. Reimbursement accuracy, staff efficiency, and patient satisfaction all stem from better medical billing software. Patient Access Curator offers healthcare providers a way to turn claims management into denials prevention. These tools apply a proactive, preventative automated process with artificial intelligence to increase downstream revenue by reducing claims denials. Experian Health, ranked Best in KLAS in Claims Management, Clearinghouse, and Revenue Cycle Contract Management for 2024, is the leading provider of technology solutions to improve healthcare reimbursement. Experian Health solutions have helped many healthcare providers obliterate claims denials. In 2023, the organization acquired Wave HDC, an AI-powered healthcare data curation solution leveraging the latest AI technology innovations for a better revenue cycle. To find out more, contact Experian Health today.

Technology has a long track record of improving patient care. But humans are now entering uncharted waters as the latest wave of digital tools impact healthcare clinical and administrative workflows. Technology advancements in artificial intelligence (AI) have spawned a fourth industrial revolution. According to the World Economic Forum, it's a time in history “that will fundamentally alter the way we live, work, and relate to one another. In its scale, scope, and complexity, the transformation will be unlike anything humankind has experienced before.” New developments in AI and automation in healthcare will offer numerous benefits to providers. The impact of recent technology advancements in healthcare is staggering. New AI and automation tools can detect human illnesses faster, monitor patients in the privacy of their homes, and streamline laborious administrative healthcare workflows to save providers up to $360 billion annually. The impact of AI and automation in healthcare is just beginning. Here are three ways these tools can help prevent and reduce claim denials, alleviate staff workloads and improve the patient experience. 1. AI and automation helps lessen claims errors Experian Health's State of Claims Survey 2022 reported that 61% of providers rely too heavily on manual processes and lack the automation necessary to streamline reimbursement. Billions of dollars are tied up in rejected claims; healthcare professionals say up to 15% of their claims are denied. However, many denials are preventable simply by eliminating human error stemming from manual workflows. When paperwork is still done by hand, mistakes in eligibility verification or incorrect insurance information are all too common. Some of the typical reasons for claims denials include data entry errors. Claims are complex, and providers handle most revenue cycle tasks manually, so it's common for incorrect insurance details, eligibility verification problems, or other inaccurate or missing information to make it through to claims submission. Far from being science fiction, the newest AI-powered administrative tools can scan patient claims data to detect errors that lead to denials. Given that diagnostic errors alone cost more than $100 billion and affect 12 million Americans annually, this new breed of AI tools offers providers a way to improve care delivery while lessening the endless hassle of claims denials. AI and automation tools can help eliminate up to errors that lead to denied claims. For example: Patient Access Curator automates insurance eligibility and coverage, scanning patient documentation for inaccurate information. The software uses AI and robotic process automation (RPA) to reduce manual errors. AI Advantage™ works to prevent denials before they happen: AI Advantage -Predictive Denials spots claim errors before submission to the payer. It's an early warning system designed to reduce denials by red flagging claims errors. But it also flags claims that fail to meet payer requirements—even if those requirements have recently changed. 2. AI and automation reduces manual processes and staff burnout Manual processes in healthcare contribute significantly to burnout, which affects nearly 50% of staff. The cost of staff burnout and preventable turnover runs around $4.6 billion annually. However, overworked staff leads to mistakes in manual processes and ultimately claim denials, so the cost of burnout directly affects the revenue cycle.Experian Health's 2023 staffing survey shows 100% of healthcare providers say staffing shortages have impacted their revenue cycle. But staff burnout and turnover affect more than reimbursement—more than 80% say it also negatively impacts the patient experience. AI and automation in healthcare can help alleviate the overwork that many staffers feel. Experian Health offers solutions to automate manual tasks, free up staff time, and reduce the volume of claims denials. ClaimSource® reduces the industry's average claims denial rate of 10% or higher to 4% or less. This software automatically scans claims, payer compliance, insurance eligibility, and patient demographics to spot the errors that lead to denials. Automating claims submission lessens the administrative burden and improves the work/life balance for overburdened staff. AI Advantage - Denial Triage covers any claims that end up rejected, prioritizing claims with the highest rate of ROI for providers. The solution uses artificial intelligence to help staff organize their efforts toward the highest revenue generating opportunities to increase revenue collection. It can lessen workloads and help teams work smarter for a higher return and better bottom line. 3. AI and automation in healthcare improves patient experiences Automation improves the patient journey. Experian Health and PYMNTS research show positive patient experience starts with self-service scheduling and registration. This kind of digital front door puts control back in the hands of patients, who are frustrated by time-consuming administrative processes. Patients have high expectations for better tech experiences throughout their healthcare encounters. Experian Health offers solutions that give customers exactly what they demand. For example: Patient Scheduling software allows 24/7 online access to appointment setting tools. In addition to making a more convenient and accessible scheduling process, this tool reduces the time it takes to set an appointment by 50%. The benefits for healthcare providers include a higher patient show rate (89% on average) and higher patient volumes (32% more patients per month). Patient Financial Advisor offers seamless, automated service estimates that go straight to the patient's favorite digital device. The tool creates a transparent payment process to help patients understand their treatment's cost and payment options. Patient Financial Advisor integrates with a secure online payment portal. These tools establish financial accountability up front while eliminating unnecessary surprises that affect the provider/patient relationship. Benefits of AI and automation in healthcare AI and automation in healthcare are changing how patients experience care delivery, how providers interact with their customers, and how clinicians manage getting paid. The benefits of using these tools include: Faster and more accurate patient diagnoses. Fewer patient readmissions and more proactive care management. Streamlined administrative tasks to reduce claims denials and improve the revenue cycle. Experian Health offers a suite of technology solutions, including a revenue cycle data curator package, to help providers get paid faster, free up staff time, and improve the patient experience. These solutions can help healthcare organizations achieve their goals by harnessing the latest AI and automation technologies to work smarter. Connect with an Experian Health expert today.

Claims denials are a thorn in the side of any healthcare organization. Even with claims denial mitigation tools and processes in place, denials are growing. In Experian Health's State of Claims 2022 report, 30 percent of respondents said denials increased between 10% –15% annually. To combat rising denials, ensure faster reimbursements, and improve the revenue cycle, healthcare providers need new claims technology that focuses on efficiency. In this post, learn about the common challenges in traditional claims processing and how to implement automated or AI-based claims management technology to drive healthcare revenue cycle efficiency. Challenges in traditional claims processing When it comes to reimbursement, the odds of being paid do not always favor the healthcare provider. The complexity of claims makes for labor-intensive workflows in traditional reimbursement processing. Data is often culled from multiple systems, including electronic health records (EHRs), paper files, diagnoses, test results, insurance verification, and more. Providers lacking a streamlined set of workflows supported by claims technology, experience errors that can lead to denied claims. Three of the most common challenges in traditional claims processing include missing or incomplete claims information, payer-related problems, and a need for more staff, which slows down processing productivity. 1. Missing or incomplete claim information Missing data is also a huge issue in traditional claims processing. In fact, missing or incomplete data is one of the top reasons for claims denials, particularly in the area of prior authorization. These mistakes often begin upstream at the first point of patient contact and, if not corrected, snowball toward the inevitable denial. Compounding the problem is that disparate healthcare systems and workflows make it increasingly challenging to collect all the data effectively. The larger the healthcare provider, the more touchpoints for claims processing, creating back-and-forth workflows that can lead to miscommunication or the loss of information. 2. Payer-related challenges Just keeping up with changes in payer requirements is a full-time job. Payers often change reimbursement requirements, and providers aren't aware of these new adjudication rules. It requires strict monitoring of all payers, which is impossible for organizations to manage. Prior authorizations are also increasingly burdensome for providers to handle. An AMA survey found that 88 percent of physicians said these burdens were high or extremely high. Providers estimated they process 45 prior authorizations weekly, equivalent to 14 hours of staff time. 3. Reduced or new staff can't keep pace Another challenge is not having the workforce necessary to review claims to identify errors. Workforce shortages continue to impact every healthcare area. The chronic challenge of high workloads and short staffing means most teams work as quickly as possible, leading to preventable mistakes. Without advanced claim technology, staff manually handle heavy workloads, which is driving denials through the roof. The lack of staff also affects traditional claims processing by slowing denials resubmissions. A less efficient denials management process directly affects provider cash flow, creating more delays in getting paid. Resolving these challenges requires modern, advanced claims technology powered by automation and artificial intelligence (AI). By leveraging this technology for claims management, healthcare providers can solve these problems for greater reimbursement efficiency and a better bottom line. Best practices for implementing AI-based claims management technology Experian Health data shows 51% of healthcare providers currently leverage some software automation. However, only 11% had integrated AI technology into their organization. Mounting evidence suggests preventing healthcare claims denials starts with innovative AI-driven claims management technology. AI and automation applied to a claim technology solution can prevent claims denials on the front-end of the patient encounter and improve denial management on the back-end of the process. When evaluating how to implement advanced claim technology, consider these best practices: Start by identifying the pain points in existing claims processing workflows. Review claims denials and mitigation data and talk with existing staff to develop this list. If the organization leverages legacy reimbursement tools, consider how efficiency gaps affect the organization. Consider organizational goals and objectives for replacing manual workflows or upgrading legacy claims management technology. As the organization explores the benefits of advanced claim technology featuring AI, develop use cases for employing these tools for more effective claims management. Compare new product features to these real-life scenarios. Seek stakeholder feedback. All technology rollouts require significant buy-in at every level in the organization. Don't miss engaging with the boots-on-the-ground workforce using the claims technology Ensure the organization has the infrastructure to support the new platform long after it goes live. When evaluating new digital tools, keep these things in mind: Select AI-based claims technology that utilizes workflow customization to manage the entire reimbursement cycle. Seek out a solution that automatically reviews each line in a claim to check for errors so that first submissions are accurate. Leverage a system with automation features that eliminate error-prone manual processes. Choose a platform that enables denial prediction and mitigation. Find a product with denials workflows and enhanced claims monitoring functionality. AI technology is the game-changer for healthcare's skyrocketing claim denial challenges. These new tools deliver immediate value to an increasingly disjointed and complex reimbursement process. With the right technology, healthcare providers improve the claims processing efficiency to get paid faster. Transformative impact of Experian Health's advanced claims technology Experian Health is a leader in digitally transforming traditional claims processing. AI-powered technology can increase staff efficiency at every stage of the claims management process. Experian Health's AI Advantage™, part of the Best in KLAS ClaimSource® platform, is transforming provider claims processing. This software reduces the need for additional staff by automating manual tasks. It lessens the burden on existing teams by lightening their claims processing and denials management workloads. AI Advantage has two primary solutions affecting every stage of the claims management process: Predictive Denials identify undocumented payer rules resulting in new denials. This AI-driven solution finds the claims most likely to fail, flagging them back to payment processing for correction before they're even submitted to the payer. Denial Triage manages prioritization of denied claims. Advanced algorithms in this solution identify and flag denials based on their potential value. Organizations maximize their returns on denied claims by focusing on the resubmissions with the highest financial impact. It removes the guesswork from reworking claims, lessening staff workloads by eliminating time wasted on low-value cases. Another solution, Patient Access Curator, uses AI and robotic process automation to enable healthcare staff to capture all patient data at registration, with a single click solution that returns multiple results - all in 30 seconds.  Experian Health's automated and AI-fueled advanced claim technology improves provider reimbursement efficiency at every stage of the process. The efficiency-related benefits of AI for claims management include avoiding denials, accelerating denial mitigation, and getting paid faster. To explore these tools—and their extraordinary ROI, contact the Experian Health team today.

“As the IU Health Revenue Cycle team rallied to respond to the claims processing disruption, we were uniquely positioned with our long-time Experian partnership to quickly re-institute critical claims routines and restore a significant volume of claims transmissions.  This would not have been possible without Experian's nimble and comprehensive approach, immediately applying talented and committed resources that leveraged existing Experian platform infrastructure.” – Bryan Daniels, Vice President Revenue Cycle Solutions, IU Health Challenge Indiana University Health (IU Health) is the largest network of physicians in Indiana comprised of over 38,000 team members and 2,717 available beds. Based in Indianapolis, Indiana, the organization has dozens of facilities statewide and is on a mission to make the state one of the healthiest in the nation. In February 2024, IU Health found itself impacted by the cybersecurity incident so many providers across the country abruptly faced. They were unable to send claims to insurance companies and their revenue cycle operations came to screeching halt. Knowing they needed a trusted solution fast, the revenue cycle leadership team asked Experian Health if they could help. Solution Conversations advanced quickly and the Experian Health team was able to implement its Best in KLAS ClaimSource® platform within a week. ClaimSource is an innovative claims management solution designed for scalability and improves revenue streams by minimizing denials. By using automation, it boosts operational efficiency by prioritizing claims, payments, and denials, allowing users to tackle high-impact accounts promptly. Outcome Thanks to ClaimSource, IU Health achieved the following results: Accelerated $632 million in claims transmissions in the first five days of business. Processed $1.1B of claims backlog by March 27.  “We value our longstanding partnership with IU Health and it's very rewarding that we were able to help in a very critical situation,” said Jason Considine, Experian Health's Chief Commercial Officer. “We know IU Health places the utmost importance on patient care, and being an important part of our client's solution to deliver on their service commitment is reflective of our service commitment to simplify healthcare.” Learn more about how ClaimSource can help your healthcare organization accelerate cash flow, reduce denials and optimize efficiency.

Healthcare leaders often zero in on how uninsured rates affect their bottom line. But another patient group presents a quieter financial dilemma for providers: those with multiple active health plans. In these cases, it's important to ensure each plan pays the right amount – in the right order. Should any confusion arise, providers may end up with their claims being denied, resulting in underpayments. This is where the coordination of benefits (COB) process comes in. What is coordination of benefits (COB) and why is it important? When a patient is covered by more than one plan, the “coordination of benefits” process kicks in to help health plans figure out their respective payment responsibilities. With patients often having multiple insurance policies, ensuring that each policy pays its share is vital. The purpose of coordination of benefits is to prevent overpayment or duplication of benefits, ensuring that the total benefits paid do not exceed the actual cost of the service received. Integrating a digital COB solution within registration and scheduling workflows can help providers ensure they bill primary and secondary payers correctly, preventing unnecessary claim denials. Challenges of coordination of benefits  Coordination of Benefits is a pivotal aspect of RCM, but it's not without its hurdles. Here's a look at the complexities that often arise:  Overlapping Policies: Determining which policy pays first can be confusing. Patients with dual coverage might not always be aware of the hierarchy, leading to billing complications. And many legacy systems only select the primary, without consideration for secondary or tertiary. And regional plans add another layer of complexity.  Claim Denials: Incorrect coordination of benefits can lead to claim denials or overpayments. This not only affects revenue but also strains the patient-provider relationship when patients are billed incorrectly.  Administrative Burden: Manual COB verification is time-consuming and prone to errors. Staff often spend hours cross-referencing policies, which could be better spent on patient care.  Coordination of benefits: the dream vs. reality In an ideal world, patients would register for care weeks ahead of their scheduled treatment. During the registration process, they would inform the provider of all their active insurance coverage, with correct and complete details close to hand. No plan would go unmentioned, and no policy number misplaced. Registration staff would quickly enter the information into their EMR without error, so coverage could be verified in real-time. The reality is far different. Recent findings show that 65% of consumers struggle to understand what their health insurance covers. They do not carry copies of their insurance cards. They may not be aware that they are covered under a relative's health plan. Patient access teams are under-staffed and over-stretched, with little time to ask guiding questions that would uncover additional insurance. Coordination of benefits efforts should start as soon as it becomes apparent that a patient has active coverage under multiple plans. Unfortunately, the messy reality of coverage discovery and patient registration means patients and providers are left in the dark until a claim is denied. The payer rejects the claim for a COB-related reason, leaving billers with no clue how to resolve it. The problem gets worse from there. Automating coordination of benefits for faster, cleaner claims As with all aspects of healthcare billing, there are many complex rules and regulations governing COB transactions. Under HIPAA, health plans and payers (including Medicare and Medicaid) must coordinate benefits for each patient and determine the primary and secondary payers. Tracking this manually is extremely challenging for providers: using the information provided by the patient (which may or may not be accurate), staff would contact each payer by phone or email to verify coverage. They would then review the COB rules and guidelines for each health plan to determine the primary payer and follow specific rules for billing secondary payers. It's no wonder that COB transactions are now among the most automated administrative tasks. Automating coordination of benefits not only saves staff time, but also increases the chances of finding all active coverage, collating complete insurance profiles for the patient, and making an accurate primacy determination. Digital systems also make it easier for providers and payers to communicate with one another, facilitating smoother dispute resolution and regulatory compliance. Patient Access Curator brings real-time COB to EH clients In late 2023, Experian Health acquired Wave HDC, bringing clients a new and unrivalled package of real-time coverage and benefits solutions based on AI-powered data curation. This new solution, Patient Access Curator, helps healthcare billing teams prevent claim denials in seconds through real-time data analysis. This includes COB curation, which automatically analyzes payer responses to identify hidden cues that staff cannot see. If other insurance is identified, the tool alerts the user and triggers additional queries to verify active coverage and build a complete insurance profile for the patient. Each policy is then analyzed further to determine the patient's primary, secondary and tertiary coverage, reliably sifting out any non-billable coverage. Since 2020, the technology powering Patient Access Curator has prevented denials amounting to more than $1 billion. Integrating coordination of benefits automation yields savings throughout the revenue cycle Integrating COB automation with other RCM tools, such as coverage discovery and eligibility verification, means providers can prevent and manage denials in a single workflow. Doing this during patient registration allows teams to resolve issues in the early stages of the revenue cycle, rather than wait to deal with them once claims are denied. While catching errors on the front-end results in faster patient registration and clean claims first time, the tool adds value later in the revenue cycle, too. Streamlining the correction process prevents revenue loss and reduces the need for manual intervention. Here's how these use cases look in practice: In one multistate practice, the technology automated COB curation with insurance verification during patient registration. This enabled primary coverage corrections for 12% of patient registrations and identified undocumented Medicare and Medicaid coverages for 6% of registrations. Left unchecked, these omissions would have resulted in denials, delays, and missed revenue opportunities. The technology was deployed in the denials workflow at a large health system, where it identified COB corrections for 92% of all COB denials. Of these, 60% were immediately refiled to the correct primary payer, minimizing delays in revenue recovery. In the remaining claims, the tool found evidence of inaccurate or outdated third-party liability records within payer claim adjudication systems. Providers urgently need revenue cycle processes to be as efficient and reliable as possible – especially when dealing with patients with multiple, complex health plans. A powerful denial prevention solution that slots neatly into the registration workflow means they can maximize revenue with minimal human intervention. And with accurate results delivered in seconds, Patient Access Curator could be just what the doctor ordered. Get in touch today to find out more about coordination of benefits automation and discuss other ways to increase efficiency on the front-end of the revenue cycle, using Patient Access Curator.

Labor shortages and the uptick in claim denials are undoubtedly putting heavy financial strain on healthcare providers. Could automated claim denial prevention help ease the pressure? In a recent webinar, Jason Considine, Chief Commercial Officer at Experian Health, and Jordan Levitt, Co-founder at Wave HDC (recently acquired by Experian Health), discussed strategies to tackle denials head-on in the coming year. This article summarizes the key insights, including a new automated one-click denial prevention tool that shifts denials management to the front end of the revenue cycle. 5 revenue cycle challenges causing claim denials and strained margins To start, Considine opened the webinar with a discussion of the root causes of denials. These often originate during registration, and for many providers, “registration and data integrity continue to be a problem.” A fifth of denials are attributed to just five key issues: Coordination of benefits (COB) denials, which account for a major portion of denials as more patients have secondary and tertiary coverage; Contingency fees, which eat up margins in exchange for information that providers should be able to obtain themselves during registration; Labor costs, which can increase with labor-saving automations that push manual input downstream; Epic plan mapping, which becomes increasingly complex and error-prone as payer requirements evolve; Transactional pricing, where “pay-per-click” pricing models disincentivize providers from using registration tools to find patient information during registration. These interrelated issues should be solved with one up-front revenue cycle management (RCM) solution, rather than piecemeal fixes that are implemented later. According to Considine: “Vendors tend to offer ways to solve these problems after the patient leaves, but really we should have gotten the right information right up front. Pushing problem-solving downstream means you need more people to manage these solutions, you've got more vendors to manage, and you end up staffing denial management departments and throwing more people at the problem.” Shifting from denial management to denial prevention Part of the challenge is the sheer volume of patient information that must be collected from the start. Staff interact with multiple systems to collate, check and coordinate data on eligibility, COB, Medicare Beneficiary Identifiers, demographics and coverage. Many of these data points can be points of failure if the wrong information is captured and penetrates the rest of the system. This makes patient access the perfect place to solve the denials problem. Levitt says this is exactly what Wave HDC set out to do when they developed the technology that underpins Patient Access Curator. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within two to thirty seconds.” Patient Access Curator prevents denials by capturing all patient data at registration through a single click solution that returns multiple results in less than a minute. It's fast because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer. This means data can be transferred easily between interfaces. Levitt explained how the tool builds a “perimeter defense against bad data,” by ensuring data accuracy from the start. Bad data is less likely to propagate through the system, which reduces the risk of denials. As a result, clients using the tool have been able to reduce contingency volume by over 60%. Introducing the next generation of smart RCM technology Many organizations are investing in staffing to address claim denials, but this approach is not effective in the long run. Levitt described how preventing denials calls for technology that's built for today's challenges. “Most tools out there are built to manage the problems of the last twenty years. But twenty years ago, we didn't really have COB issues. Patients were either insured or uninsured. Now, some are over-insured and some are under-insured. You see more patients come in with one insurance card in their hand, but with two, three, or four other coverages. It's much more complex. Patient Access Curator makes it simple by bundling all the transactions into one.” The technology uses artificial intelligence, in-memory analytics, and robotic process automation to verify eligibility and COB, find and fix patient identifiers, check contact information, and generate information about the patient's propensity to pay. And the result? Providers can simplify denials management even as the insurance and operational landscape becomes more complex. Watch the webinar to hear the full discussion and find out more about how Patient Access Curator helps healthcare organizations capture accurate patient information at registration with a single click.

In a strategic move that will take claims management to the next level, Experian Health recently acquired Wave HDC, a healthcare technology company specializing in AI-guided data capture and curation. The acquisition brings together the two companies' capabilities to offer healthcare organizations faster and more accurate healthcare coverage identification. With this acquisition comes Patient Access Curator, a new solution that uses artificial intelligence (AI) to revolutionize the claims management process. Tom Cox, President at Experian Health, says, “With our vast clearinghouse data resources and Wave HDC's technology and expertise in insurance data capture processes, Experian Health now offers the best eligibility and insurance identification products in the market.” This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds. Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. This session offers live Q&A with Experian Health Product Leadership. Register now Prevent denials on the front end Managing claims effectively – or more specifically, preventing denials – is one of the biggest challenges for providers. In a 2022 survey by Experian Health, 72% of respondents said reducing denials was their top priority, citing reasons including payer policy changes, reimbursement delays, and a rise in the number of errors and denials. Most issues that lead to denials crop up early in the revenue cycle, when information is missed or captured incorrectly during patient registration. For this reason, it makes sense to focus denial prevention strategies on the front end. With so much data to capture, manual strategies are bound to stumble. Unfortunately, many digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility and check for any billable coverage that might have been missed. Experian Health's industry-leading claims management products are designed to simplify these processes. The integration of Wave HDC's AI-powered data capture technology strengthens that offer with capabilities previously not available. As Cox says: “Our mission is to simplify healthcare, and this move allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” For Jordan Levitt, co-founder of Wave HDC, the merger is a chance to bring their unique technology to more healthcare organizations. “We believe this integration will have a powerful impact for the healthcare industry, improving financial solvency and efficiencies for providers through more accurate medical billing, resulting in potentially more reimbursement, faster.” Introducing Patient Access Curator: Claims management in a single click Wave HDC's technology captures and processes patient insurance data at registration using an “if-then” logic that returns multiple data points from a single inquiry, in 30 seconds. Through Patient Access Curator, registration staff can leverage this technology to collect and verify much of the information they need to compile an accurate claim, with just a single click. In a matter of seconds, they'll have a comprehensive readout of the following: Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps; Coordination of Benefits (COB): Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing; Medicare Beneficiary Identifiers (MBI): PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support; Coverage discovery and financial status: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches, and provides insights into the patient's propensity to pay; Demographics: Lastly, but by no means least, the platform can quickly check and correct patient contact information. Providers can hear more about shifting denials management to the front end of the revenue cycle with Patient Access Curator on a recent on-demand webinar hosted by Jordan Levitt and Jason Considine, Chief Commercial Officer at Experian Health. On the webinar, Levitt explains that Patient Access Curator achieves such speedy results “because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer.” This means data can be transferred easily between interfaces. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within thirty seconds.” Maximize dollars, minimize workload Patient Access Curator moves away from manual methods and verifies eligibility and coverage automatically, quickly and accurately. But the platform promises more than efficiency; with this technology, Wave HDC has prevented denials of over $1 billion since 2020. At a time when revenue cycles are under increasing pressure from changing payer rules, labor dynamics and operational constraints, the new integration offers a long-awaited boost to both reimbursement rates and productivity. Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us

Artificial intelligence (AI) and computer automation are finally beginning to impact healthcare. Payers are implementing generative AI to improve the customer experience. Researchers at Stanford use AI to review X-rays and detect pathologies in seconds. Today, AI and automation can remind patients about appointments and even provide a portion of their treatment via robotic surgery devices. While groundbreaking AI and automation technologies are in the news, adoption by the majority of healthcare providers has been slow despite research showing these tools could eliminate up to $360 billion in spending. It's a startling statistic that illustrates the reality of AI and automation applied to the revenue cycle: These tools quite literally can pay for themselves. The case for applying artificial intelligence and automation in healthcare Successful revenue cycles depend on thousands of daily tasks, which means efficiency lies at the heart of these endeavors. However, there are a lot of improvement to be made. Experian Health's State of Claims Survey 2022 shows the current state of the average healthcare revenue cycle: Reimbursement cycles are running longer. Claim errors are on the rise. Denials are increasing. More than one-half of U.S. hospitals reported financial losses in 2022. A 2023 America Hospital Report (AHA) report showed: 84% of hospitals admit the cost of complying with payer reimbursement requirements is increasing. 95% report spending more time on pursuing prior authorization approval. Over 50% of hospitals and health systems have more than $100 million tied up in A/R for claims six months old. These challenges stem from the increasing complexities of working with third-party payers, but also the by-hand human workflows embedded within provider revenue cycles. The State of Claims Survey 2022 showed that 61% of providers say they rely too heavily on manual processes and lack the automation they need to streamline reimbursement. As costs rise and revenue cycles tighten, there is increasing pressure to do more with less—faster. However, chronic healthcare staffing shortages have only exacerbated how hard it is for providers to get paid. Technology solves many of the problems plaguing healthcare's revenue cycle. AI and automation offer better revenue cycle management tools with fewer errors, less manual work, and more streamlined processes. How AI and automation improves revenue cycles Increasingly complicated reimbursement processes are the perfect testing ground for new technologies. These tools can improve the revenue cycle from the first point of patient contact to collections long after the procedure is over. For example, AI and automation software can greatly reduce errors and increase the accuracy of claims information before submission. When billing becomes more accurate, it lessens the volume of rejected claims, which take up an inordinate amount of staff resources and lengthen the time from service delivery to reimbursement. But AI and automation also impact the backend of the patient encounter by helping collections teams prioritize accounts most likely to pay. Four applications for AI and automation in the revenue cycle include: 1. Applying automation to patient registration The revenue cycle begins at patient registration, and that's also where providers can begin to apply technology to increase cash flow downstream. Patient registration is often cumbersome, an in-person process tied to a clipboard, paper, and open office hours. Yet Experian Health's State of Patient Access 2023 report shows that 73% of patients want to handle these processes online. Self-scheduling offers patients more flexibility for scheduling appointments when they want and on their preferred digital device. It can remove the friction from a frustratingly manual paperwork process while decreasing no-shows with automated messaging by text and email. Experian Health's automated patient scheduling software reduces time spent on traditionally manual scheduling tasks by 50%. Providers that select these tools increase their patient show rate to nearly 90%. From a revenue cycle perspective, providers that implement online self-service scheduling can see up to 32% more patients each month—which is money in the bank. 2. Finding hidden financial resources to reduce bad debt Experian Health's Coverage Discovery® automates the insurance verification process to match patients' responsibility with the best financial resources possible given their policy limits. Coverage Discovery scans proprietary databases and historical information for primary, secondary, and tertiary coverage. The platform seeks to find all available financial resources to lower the volume of accounts that end up as write-offs or in collections. In 2022, Coverage Discovery found $64.6 billion in patient coverage. In 2023, this software discovered previously unknown financial options for 32.1% of patient accounts, giving these customers more options for reducing debt. 3. Preventing denials by improving data quality Many claims are rejected by payers each day simply due to human error. Some of the most common reasons for claims errors include missing or inaccurate information caused by manual processes. From eligibility verification errors to incorrect insurance details, when paperwork is still by hand and this complex, it's far more likely to make an error than not. Experian Health's Patient Access Curator software automatically verifies eligibility and coverage while scanning patient documentation for obsolete or inaccurate data. The software leverages artificial intelligence and robotic process automation (RPA) to apply computer rigor to previously manual workflows to reduce manual errors. Significantly, this new technology performs these tasks in seconds, freeing up staff time and improving the patient experience. 4. Using artificial intelligence to prevent and mitigate denials How much does the endless pursuit of denials management tie up potential revenue? One survey showed half of hospitals report more than $100 million in delayed or unpaid claims at least six months old. The good news is that 85% of the errors that lead to denied claims are preventable with the help of existing technology. Experian Health's AI Advantage™ solution works in two critical areas to prevent denials before they happen—and correct any denied claims quickly: At the front end of the claim, by correcting errors before submission. AI Advantage - Predictive Denials spots the submissions most likely to kick back from the payer. This early warning system reduces the volume of denials by flagging claims with errors stemming from human mistakes or payer requirements changes. At the back end of the claim, for those rejected by the payer. AI Advantage - Denial Triage takes the volume of claims rejections and prioritizes them by those with the highest ROI for the provider organization. Not all denials offer the same volume or potential for revenue collection. This solution helps prioritize the highest returns quickly to increase revenue collection. Benefits of applying AI and automation to healthcare's revenue cycle There is little argument across the healthcare industry that the strategies that once worked to create a healthy revenue cycle still apply. Fortunately, today's AI and automation software allow these organizations to modernize their approach to these complexities—and win the revenue cycle game. The benefits of applying modern AI and automation tools at every point of the revenue cycle are substantial: Faster and more accurate patient scheduling and registration. No more manual data searches that tie up staff time. Fewer data entry tasks that lead to errors. Fewer claim denials. Less time spent chasing claims. Fewer days in A/R. More cash on hand. A high-performing revenue cycle is possible with the latest technology tools. Experian Health offers a suite of technology solutions that utilize artificial intelligence and automation designed to get providers paid faster, free up staff time, and improve the patient experience. Improving the revenue cycle is a necessity, and Experian Health helps healthcare organizations achieve this goal.

The relationship between hospitals and payers has often carried an undercurrent of tension. Stacks of paperwork, complex claims rules and manual adjustments are a recipe for disrupted cash flow and time-consuming rework. With profit margins hanging in the balance, providers need the reimbursement process to move forward without a hitch. To the relief of revenue cycle managers, recent developments in digital technology are paving the way for more effective claims management. Case in point: Experian Health's recent acquisition of Wave HDC, which brings together a suite of advanced patient registration solutions for faster and more accurate claims management at the front end of the process. Shifting sands in the hospital-payer relationship could increase denials For healthcare organizations, getting paid in full- and on-time hinges on seamless communications with payers. Any missteps can lead to revenue losses, with denied claims and delayed payments being the outcomes providers most want to avoid. Payers will automatically deny claims that have errors or missing information, while disputes and slow processing times can seriously hamper a hospital's cash flow. The sources of potential conflict have been pretty steady over time, stemming from complex billing processes, frequent changes to payers' requirements, and a lack of standardization between payers.  Tension created by the cost of services and the need to control healthcare costs is a constant in the revenue cycle. Recently, a major shift in dynamics has occurred with the widespread adoption of artificial intelligence by payers. This enables them to process – and deny – claims with unprecedented speed and scale, leaving providers struggling to catch up. On a recent webinar, Makenzie Smith, Experian Health Product Manager for AI AdvantageTM, explained how this change was reshaping the relationship between payers and providers: “So many payer decisions are now being driven by artificial intelligence. Insurers are reviewing and denying at scale using intelligent logic, leaving providers fighting harder for every dollar… Many revenue cycle managers will stick in their comfort zone because operating margins are tight and changing course seems risky. But given this change in payer behavior, the cost of staying the course could put organizations at risk.” How AI-powered revenue cycle management solutions help close the gap between payers and providers Providers are increasingly leveraging digital technology to level the playing field with payers. Integrated software and automation give revenue cycle management teams the right data in the right format and at the right time to respond to queries promptly and accurately. These solutions enable teams to work more efficiently, so they can process more claims in less time. Experian Health's flagship AI-based claims management solution, AI AdvantageTM, is a prime example. This tool predicts and prevents denials by identifying patterns in payer behavior and flagging claims with a high probability of denial so specialists can intervene before the claim is sent to the payer. This works alongside ClaimSource®, which automates clean claim submissions at scale. Using a single application, all claims are prepared and submitted with all necessary documentation, reducing the risk of denial due to missing or inaccurate information. Integrating Wave HDC's data capture technology for comprehensive claims management In November 2023, Experian Health acquired Wave HDC, which specializes in using AI-guided solutions to capture and process patient insurance data at registration with unrivalled speed and accuracy. This gives Experian Health clients access to a single denial management solution, known as Patient Access Curator. This new technology is a single click solution that spans eligibility verification, coordination of benefits, coverage and financial status checks with near-100% accuracy in less than 30 seconds. Crucial registration data can be captured in real time as soon as the patient checks in for an appointment, with no need to chase and update data post-registration. A single inquiry can search for all the essential insurance and patient demographics instantly, enabling better use of staff resources and smoother communications with payers. Tom Cox, President of Experian Health, says the move “allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” Accurate patient data from the outset is key to preventing downstream denials, many of which originate in patient access. By reducing errors and enabling faster processing times, this comprehensive approach to denial management will help strengthen the relationship between providers and payers, ensuring timely payments and clean claims. Contact Experian Health today to find out how AI and automation can help build a successful relationship between providers and payers – and drive down denials.