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What happens when payers don't comply with contract terms? What if a provider overlooks the fine print? Contracts between healthcare providers and payers are supposed to make each party's responsibilities crystal clear. The reality is often murky. Providers face expensive consequences if they fail to adhere to payer policies – yet they often struggle to hold payers to the same level of accountability when it comes to being paid on time and in full. That's why good contract management matters. Ensuring both parties are aligned from the start protects providers from unmet expectations and revenue loss. This article looks at how contract management software for healthcare helps streamline this process, reduce misunderstandings and secure a more predictable revenue cycle. Understanding contract management in healthcare Contract management in healthcare includes all the processes involved in negotiating, executing and monitoring agreements between payers and providers. As healthcare services (and how they're financed) become more complex, it's increasingly important that these contracts are airtight. Providers need assurance of proper reimbursement, while payers want to control costs. Robust contract management helps avoid disputes so both sides can meet their financial and operational goals and maintain an effective working relationship. As Timothy Daye, Director of Managed Care Contracting at Duke Health Integrated Practice, puts it, “It's about getting paid correctly per your contracts, so you don't leave money on the table.” Challenges in healthcare contract management The challenges that could leave money on the table fall into four main areas: Complex negotiations: Providers handle thousands of contracts with multiple plans and provisions, all subject to changing regulations. Managing these negotiations can be time-consuming and overwhelming. Limited data analysis and visibility: To negotiate better contracts, providers need to factor in performance data for existing contracts and current figures for patient mix and volume. Evaluating contract terms is extremely difficult without access to the right data and models. Conflicts over claim denials: Underpayments and denials are the biggest challenges for providers, with payers reportedly denying 15% of all claims initially. Disputes over claims, payments and contract interpretations strain relationships and disrupt revenue cycle performance. Reliance on inefficient and manual processes: Poorly defined processes and miscommunications contribute to a lack of clarity when it comes to contract governance. Paper-based systems that lead to errors, delays and millions of wasted dollars don't fulfill the brief. Key features of contract management software To tackle these challenges, healthcare providers are increasingly turning to contract management software. Experian Health's Contract Manager solution improves efficiency and accelerates reimbursement by automatically checking claims before submission and validating expected reimbursement against allowed amounts. Here's how it works: A team of contract analysts assesses the organization’s contract terms, fee schedules and payment policies to clarify what’s required and when. Accurate rates and authorization rules are populated automatically to minimize pricing errors and reduce manual effort. Contract mapping and claim valuation logic reduces the risk of audits and penalties, while automated alerts help providers ensure their contracts comply with current healthcare regulations. Configurable online dashboards give staff immediate access to reimbursement reports, so they can compare expected and allowable amounts and monitor performance. Unlike manual systems, contract management software can be easily scaled for organizations of any size. Because it integrates seamlessly with existing hospital information and practice management systems, Contract Manager can audit claims for a single medical practice or a large health system with one solution. Watch the webinar: Hear how OrthoTennessee used Contract Manager to validate reimbursements, pursue bulk appeals and recover underpayments at scale. Benefits of using contract management software Simplifying contract management with software results in three main benefits for providers: 1. Increase revenue by validating reimbursements and reducing underpayments Automated oversight of payer contracts makes it easier to find discrepancies between the amounts billed and the rates agreed in payer contracts, resulting in increased revenue. This software helps providers avoid missing out on reimbursements because of buried contract clauses and supports contract-based appeals to recover underpayments. 2. Negotiate better terms (and relationships) with payers Contract management software allows providers to evaluate contract results and use that information to assess proposed terms for new contracts. This puts providers on a stronger footing in negotiations and allows them to agree to more favorable terms. More effective communications and quicker dispute resolutions also improve provider-payer relationships. 3. Streamline workflows for speed and scale Finally, automated workflows combine more accurate data to process claims faster, leading to a more predictable revenue cycle. They also lower administrative costs and allow staff more time to prioritize other patient-facing and revenue-building activities. For these reasons, Experian Health's Contract Manager product was ranked “Best in KLAS” and top-client rated in Black Book™ solutions in 2024. Secure financial stability with contract management software for healthcare Contract management may not be the most visible revenue cycle activity, but even a small change in terms can make or break financial goals. As providers work to cap costs while maintaining quality, contract management software has become critical in securing fair reimbursement rates and auditing payer contract performance with confidence. Find out more about how Experian Health's contract management software for healthcare providers validates reimbursements, reduces revenue loss and strengthens relationships with payers. Learn more Contact us

Despite increased access to claims management technology, claims denials are still on the rise in 2024. Contributing factors include growing healthcare costs, stricter payer reimbursement policies, and claims processing errors. Providers are seeing an uptick in nonpayment, plus an added burden on administrative staff, disrupted patient care, and hits to the bottom line. Experian Health surveyed over 200 healthcare professionals, primarily in executive or management roles, to better understand the current state of claims. The findings of the State of Claims 2024 report break down the latest health insurance claim denial statistics, reasons for denials, and providers' concerns about reimbursement. Rising healthcare costs: who will foot the bill? The U.S. healthcare system is the most expensive in the world, and costs continue to rise. In 2022, healthcare spending reached $4.5 trillion, a threefold increase from $1.4 trillion in 2000. In 2023, costs rose 7.5% to $4.8 trillion. Paying for healthcare is becoming more and more out of reach for patients and causing great concern. Over three-quarters (77%) of providers worry patients will skip out on their medical bills. Payer reimbursement challenges are also weighing heavily on healthcare leaders' minds. More than 75% are worried about nonpayment due to ever-evolving payer policy changes. They also have concerns about the pre-authorization struggles that have continued since 2022, as reported in the State of Claims 2022 survey. Hospitals are particularly feeling the financial pinch of operating within such an expensive environment and face uncertainties about meeting financial obligations on top of other major post-pandemic challenges like staff shortages. The impact of claims denials Providers continue to see claims being denied in greater numbers. In 2022, 42% of respondents said denials are increasing. The number jumped to 77% in 2024. Similarly, the time it takes to be reimbursed is increasing, per 67% of respondents. That number was 51% in 2022. In 2024, 84% of healthcare organizations will make reducing denied claims a top priority. The Journal of Managed Care & Specialty Pharmacy reports that the burden of denied claims totals around $260 billion annually. The impact of claim denials is far-reaching, affecting the patient experience and revenue cycles. Struggles with claims also burden staff and drain resources, contributing to even more losses. The growing challenge of data collection, verification and authorization Successful claims processing depends on accuracy. However, achieving accuracy in data collection, verification, and authorization processes remains a continued challenge for claims management teams. Nearly half of respondents (46%) in the State of Claims 2024 report identified missing or inaccurate information as the primary cause for denial. Inaccurate or missing data also creates extra steps in claims processing, resulting in the need for secondary checks and “wasted” healthcare dollars. Survey respondents reported using multiple solutions to collect all the necessary patient data for claims, with some using as many as four different products. Leveling the playing field in claims management with technology Staying on top of reimbursement requirements and processes is complex, resource-demanding and time-consuming. Inaccuracies commonplace with manual processing exacerbate issues and further extend processing and reimbursement times. However, automation and AI technology have proven effective at reducing claims denials and the burden of manual processing. “Adding AI in claims processing cuts down denials significantly,” Tom Bonner, Principal Product Manager at Experian Health, explains. AI automation quickly flags errors, allowing claims editing before payer submission. It's not science fiction—AI is the tool hospitals need for better healthcare claims denial prevention and management.” During the pandemic, providers embraced new technology to meet immediate needs; however, that momentum slowed in recent years. In 2022, survey data revealed that 62% of providers were using some form of automation and AI technology. Yet, in 2024, only 31% said they used this type of technology. Here's how claims automation can help healthcare organizations improve claims success rates: Manage the entire claims process: Using an automated, scalable claims management system, like ClaimSource®, helps reduce denials and increase revenue. Providers can manage their entire claims cycle in a single application and ensure claims are clean before submission. Submit more accurate claims: An automated claims submission tool, like ClaimScrubber, helps identify errors that typically result in denials or underpayments before submission. This results in quicker payments, less time chasing aged accounts receivables, and improved cash flow. Eliminate manual processes: Providers that use Denials Workflow Manager can target claims that need attention immediately, managing denials more effectively and increasing reimbursements significantly. Improve cash flow: Enhanced Claim Status helps providers take an early-and-often approach to monitoring claim status in the adjudication process. It eliminates manual follow-up tasks, allowing providers to respond early and accurately to pended, returned-to-provider, denied or zero-pay transactions. Prevent denials: Experian Health's AI Advantage™, an AI-driven platform, uses an organization's own historical claims data, plus Experian Health's sophisticated knowledge of payer rules, to continuously learn and adapt to an ever-changing payer policy landscape. This technology helps providers better predict and prevent claims denials, focus on high-priority claims, and boost overall revenue. Adaptation of technology is likely on the rise with 45% of healthcare leaders planning to invest in automation in the next six months. Over the next year, these investments could pay off if claims denials start to decrease as a result, prompting more healthcare organizations to boost investments in claims management technology. Download the State of Claims 2024 report to get the latest health insurance claim denial statistics, or contact us to learn how Experian Health can help with better claims management. Get the report Claims management solutions

Could a more targeted approach to patient collections help providers maximize revenue? Wooster Community Hospital (WCH) has proof that it can – to the tune of a 7.75% boost in annual collections. In a recent webinar, Kristen Shoup, Wooster's Revenue Cycle Director, and Judy Wirtz, Senior Analytics Consultant at Experian Health, shared their success in implementing a patient-centric, automated approach to collections. With Collections Optimization Manager, PatientDial and PatientText, they saw patient payments increase by $3.8 million in a single year. Watch the webinar: Learn how WCH transformed patient collections with better insights into patients' propensity to pay and automated patient outreach. Moving away from manual processes After outsourcing self-pay collections for 20 years, Wooster Community Hospital decided to bring the process in-house to give patients a better customer experience and increase cash payments. However, because they had a lean team, they needed a strategy that would make better use of staff time and ensure each patient's account was handled in the most appropriate way. Manual systems wouldn't cut it. They wanted to make better use of data and automation so staff could focus on patients who were most likely to pay and improve patient communications. Using Experian Health's Collections Optimization Manager, alongside PatientDial and PatientText proved to be the winning combination. Customizing collections with smarter segmentation The backbone of Wooster's new collections strategy is smarter segmentation. Collections Optimization Manager categorizes patients into different tiers according to their ability and likelihood to pay, using data analysis and predictive modeling. Wirtz explains how these propensity-to-pay scores, or segment scores, allow staff to tailor their collections approach and determine the right outreach for each group's needs: “Most competitors rely on historical patient payment data to calculate propensity-to-pay scores. The Experian Health segmentation score is unique, because we have access to multiple data sources, such as credit data, payment behavior, socioeconomic data and financial data. Combining these sources gives our clients a comprehensive propensity-to-pay score, which allows them to prioritize collection efforts.” Not only does the Collections Optimization Manager direct efforts to high-value patient accounts, but this tool helps the team understand patient payment patterns so they don't pursue uncollectable accounts and collect more with fewer resources. It also identifies charity eligibility, which eases pressure on patients and creates a more compassionate experience. Zero complaints with a personalized patient experience Wooster was able to use the insights generated by Collections Optimization Manager to create a more appropriate engagement strategy for each group of patients, based on their needs and preferences, and automated communications using PatientDial and PatientText. With PatientDial, Wooster automated outbound collections calls using interactive voice response (IVR). This helped patients handle payments on their own over the phone, without needing to speak to an agent. Staff can also send patients personalized text messages for an alternative but equally quick and convenient way to pay their balances. Before using these tools, patients expressed frustration at receiving collections calls at inconvenient times. Since adopting this new tailored, convenient, and unintrusive contact combination, Wooster has seen a significant improvement in patient satisfaction. The proof is in the payments Ultimately, Wooster's goal was to increase self-pay revenue. Wirtz shares that as a result of the new strategy, Wooster has seen patient payments increase by $3.8 million in just one year. The annual collection rate increased by 7.75%, with $1.47 million collected through PatientText and $485,000 through PatientDial. Encouragingly, Wooster has also seen a $600,000 drop in bad debt placements and discovered an additional $800,000 in Medicaid coverage thanks to Collections Optimization Manager. Partnering for success Shoup and Wirtz also discussed their partnership approach to determining the optimal collections strategy for Wooster. Wirtz worked closely with the team, providing dedicated support to set up and monitor workflows, discuss any pain points, and pull out benchmarking insights. Shoup says: “Judy's been a great partner, and the team at Experian Health has been great to work with. The great thing for me was being able to show the value in the changes we made. When I first decided that we needed to bring our self-pay process back in-house, and we partnered with Experian, I needed to be able to prove that what we were doing was successful. And 100%, hands down, it has been a huge success. We have collected more money, and I can monitor that and show the results using Experian's tools.” Watch the webinar on-demand to hear the full discussion, and see how Experian Health can help your healthcare organization can use segmentation and automation to create a targeted, efficient and compassionate patient collections strategy. Watch the webinar Contact us