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.
