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Healthcare claim denials persist as a significant challenge, impacting the efficiency, affordability and timeliness of healthcare delivery and hospitals' financial well-being. They contribute a substantial portion of the staggering $265 billion annual in waste attributed to administrative complexities. On average, hospitals face a yearly loss of $5 million due to healthcare claim denials, amounting to 5% of their net patient revenue, according to the Journal of AHIMA. Yet it appears that the rise in claim denial rates continues unabated. Experian Health's State of Claims 2022 report revealed that 30% of respondents experience medical claims being denied in 10-15% of cases, and 42% confirm an increasing trend in denial rates from one year to the next. There is no question that the claims denial process is ripe for innovation, and that's where reducing healthcare claim denials with artificial intelligence (AI) comes in. Like many other sectors, healthcare providers are slowly but increasingly turning to automation and AI for more accurate data and better insights. The Experian Health survey shows over one-half of healthcare providers turn to AI-driven healthcare claims management software to reduce claim denials. "Adding AI in claims processing cuts 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." The current challenges in claims management High patient volumes and complex payer policies Experian Health's 2022 State of Claims survey revealed that reducing denials was a top priority for almost three-quarters of healthcare leaders. Why? High patient volumes mean there are more claims to process, and changing payer policies and insurance coverage compound an already overwhelming problem. An Sg2 report predicts that patient volume issues will continue over the next decade, with inpatient hospital volumes growing by 2%. This rise in patient numbers will require more data for claims management processing. Hospitals, often short-staffed, will have to allocate more resources to ensure claim approval and increase efforts to address claims denial. In addition to managing increasing patient volumes, keeping track of changing payer coverage and requirements has always been challenging for providers. The inconsistency of these payer rules and communication problems exacerbate the situation. Healthcare providers may need efficient solutions to keep up with these rule changes or allocate more time and resources to addressing and revising claims. Labor shortages and financial pressures According to a data brief from the American Hospital Association, the increasing rate of clinician burnout, the enduring effects of COVID-19, and ongoing strains on the healthcare workforce are compelling hospitals to recognize and tackle chronic labor shortages. Notably, 80% of healthcare leaders acknowledge that chronic staffing shortages present significant risks for their organizations. Increasing denial rates is one way these risks manifest. As the State of Claims 2022 report confirms, 30% of respondents mentioned staffing shortages significantly contribute to healthcare claim denials. Additionally, Experian Health's recent survey, Short Staffed for the Long-Term, which investigated the impact of healthcare staffing shortages, found that 70% of respondents facing staff shortages also experienced increasing denial rates. Labor shortages mean fewer hands on deck to deal with the claims processing workload, while financial pressures on hospitals mean the stakes are higher than ever to solve the problem of claim denials. Limitations and costs of manual claims processes Health payers deny hospital systems about $260 billion worth of inpatient claims annually. According to Experian Health's survey, manual processing and a lack of automation are the primary reasons for these medical claim denials. The State of Claims 2022 report found that 61% of respondents do not automate claims submission and denial prevention processes, leaving them to rely on manually processing claims. However, manual claims management tools simply cannot keep up with the complexities and data-intensive nature of claims processing. When claims processes are handled manually, healthcare workers are burdened with cumbersome tasks that could have been automated, there is a higher risk of errors that lead to claims denial, and there'll be more need to dedicate extra time and effort to appeal denied claims. These intensive steps necessary for manual claims processing drain staff resources and create opportunities for money and time waste that are eventually detrimental to the hospital's financial circumstances. How AI and automation address healthcare claim denials Automation and AI can ease the pressure by processing more claims in less time. They give providers better insights into their claims and denial data so they can make evidence-based operational improvements. AI tools achieve this by using machine learning and natural language processing (NLP) to identify and learn from data patterns and synthesize huge data swathes to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation in claims processing can complete rules-based, repetitive tasks with incredible speed and reliability that a person might not achieve. By using automation and AI in claims processing, healthcare providers can gain better insights into their claims and denial data, resulting in improved financial performance and greater efficiency. Tom Bonner says, "AI in healthcare claims processing maximizes the benefits of automation for better claims processing, better customer experiences and a better bottom line for healthcare providers." However, the pace of AI adoption is somewhat slower in healthcare due to legacy data management systems and data silos. As efforts to improve interoperability progress, providers will have more opportunities to deploy AI-based technology. This prediction is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for reducing claim denials with AI to help maximize reimbursements. Key benefits of AI in healthcare claims management Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software exponentially benefits claims management through its predictive, accuracy, and error-reduction capabilities. Predictive Analytics and Pattern Recognition: The benefits of AI in healthcare claims processing lie in the ability of AI-driven solutions to predict potential issues before they occur by analyzing claims and providing a probability of denial that allows the end user to intervene and determine the appropriate collection. AI can analyze patterns in historical claims data to predict future volumes and costs, so providers can plan accordingly without simply guessing at what’s to come. Error Reduction and Clean Claim Submissions: AI can also assist in identifying inaccurate claims and improve claims processing accuracy to ensure clean claim submission and efficient revenue cycle management. Case studies and real-world applications AI and automation in claims processing are helping healthcare providers overcome the challenges contributing to increasing claim denial rates. Experian Health's AI-driven and automation solutions, like AI Advantage™, enable clients to benefit from the full potential of AI and automation to minimize claim denials. How Community Medical Centers uses AI Advantage to predict and prevent healthcare claim denials Community Medical Centers (CMC), a non-profit health system in California, uses Experian Health's new solution, AI Advantage, which uses AI to prevent and reduce claim denials. Eric Eckhart, Director of Patient Financial Services, says they became early adopters to help staff keep up with the increasing rate of denials, which could no longer be managed through overtime alone. "We were looking for something technology-based to help us bring down denials and stay ahead of staff expenses. We're very happy with the results we're seeing now." AI Advantage reviews claims before they are submitted and alerts staff to any likely to be denied based on patterns in the organization's historical payment data and previous payer adjudication decisions. CMC finds this particularly useful for addressing two of the most common types of denials: those denied due to lack of prior authorization and those denied because the service is not covered. Billers need up-to-date knowledge of which services will and will not be covered, which is challenging with high staff turnover. AI Advantage eases the pressure by automatically detecting changes in how payers handle claims and flagging those at risk of denial so staff can intervene. This reduces the number of denials while facilitating more efficient use of staff time. Eckhart says that within six months of using AI Advantage, they saw 'missing prior authorization' denials decrease by 22% and 'service not covered' denials decrease by 18% without additional hires. Overall, he estimates that AI Advantage has helped his team save more than 30 hours a month in collector time: "Now I have almost a whole week a month of staff time back, and I can put that on other things. I can pull that back from outsourcing to other follow-up vendors and bring that in-house and save money. The savings have snowballed. That's really been the biggest financial impact." How Providence Health found $30M in coverage and reduced denial rates with automated eligibility checks Providence Health is a prominent health system with 56 hospitals and over 1,000 physician clinics, serving an annual patient volume of over 28 million. This magnitude of patient volume created greater issues with slow and manual payer eligibility processes and increased eligibility denials. Furthermore, in response to Epic's growing payer plan table, Providence Health sought an effective solution to merge and organize data on insurance plans, contracts, and reimbursement details and automate eligibility tracking within the system. Their search led them to Experian Health's Insurance Eligibility Verification solution. According to Emily Brown, Director of Operation Excellence, "Our search for a solution that seamlessly integrates with Epic led us to choose Experian as our preferred vendor, given their proven track record of working with Epic." Providence Health implemented Experian's Eligibility solution, including a Bad Plan Code Detection tool to catch coding errors before submission. The solution also allowed them to stay connected to over 900 payers and provide backup connectivity to over 300 additional payers for uninterrupted service. The solution's automated work queues also helped staff work more efficiently. Providence reduced denial rates, saving $18 million in potential denials in 5 months of implementing Experian's Eligibility solution. The tool also helped them find $30 million in coverage annually while reducing staff workload. How Schneck Medical Center prevents and triages denials with AI Advantage™ Schneck Medical Center delivers care to four counties in Indiana, supported by a team of over 1,000 employees, 125 volunteers, and close to 200 physicians. According to Skylar Earley, Director of Patient Financial Services, "The challenge we (Schneck Medical Center) sought to overcome by leveraging AI Advantage at our organization was just gaining more insight into how denials originate and what actions we can take to prevent those from happening." Schneck Medical Center collaborated with Experian Health to implement: AI Advantage™ — Predictive Denials and AI Advantage™ — Denial Triage. They aimed to use these tools to identify claims that were more likely to be denied so that the appropriate personnel could address them and clean them before sending them to payers. They also wanted to be able to identify and prioritize denials with the potential for revenue reimbursement that will impact their bottom lines. AI Advantage™ — Predictive Denials enabled team members to make informed and timely decisions before submitting claims. In the first six months of using the tool, Schneck achieved a 4.6% average monthly decrease in denials. The time spent on denials decreased by 4x, and flagged claims were resolved in 3–5 minutes rather than the previous 12–15 minutes per correction. With AI Advantage — Denial Triage, billers were able to redirect their effort on denials more likely to be reimbursed. This prioritization enables them to avoid wasting time on high-dollar claims that are unlikely to be paid. "We had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages," says Skylar Earley, Director of Patient Financial Services Steps to implementing AI in claims management AI Advantage works in two stages in claims management, reducing claims denial and addressing denied claims to prioritize those with the best value for reimbursement. Stage One: Predictive Denials Stage one is Predictive Denials, which uses machine learning to look for patterns in payer adjudications and identify undocumented rules that could result in new denials. As demonstrated by CMC and Schneck Medical Center, this helps providers prevent denials before they occur. Stage Two: Denial Triage Stage two is Denial Triage, which comes into play when a claim has been denied. This component uses advanced algorithms to identify and segment denials based on their potential value so staff can focus on reworking the denials that will impact their bottom line. Enhancing revenue cycle management with AI Embracing integrated workflows uncovers novel applications for reducing healthcare claim denials with AI and automation. AI Advantage seamlessly works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. These integrations amplify the benefits of each tool, giving healthcare providers better insights into their claims and denial data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Key differentiators In addition to its AI solutions, Experian Health offers solutions that automate claims processing to facilitate claims management and increase efficiency. ClaimSource® helps providers manage the entire revenue cycle by creating custom work queues and automating reimbursement processing. This intelligent healthcare claims management software ensures clean claims before they're submitted, helping to optimize the revenue cycle. The software generates accurate adjudication reports within 24 to 72 hours to speed up reimbursement. ClaimSource ranked #1 in Best in KLAS 2024, for its success in helping providers submit complete and accurate claims. This tool prevents errors and helps prepare claims for processing. Because the claims are error-free, providers can optimize the reimbursement processes and get their money even faster. Another Experian Health solution, Enhanced Claim Status, improves cash flow by responding early and accurately to denied transactions. This solution gives healthcare providers a leg up on denied, pending, return-to-provider, and zero-pay transactions. The benefits include: Provides information on exactly why the claim was denied Speeds up the denials process Automates manual claims follow-ups Integrates with HIS/PMS or ClaimSource Automation frees up staff to focus on more complex claims Denials Workflow Manager integrates with the Enhanced Claim Status solution to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. Using AI and automated solutions to prevent healthcare claim denials There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex, but human error plays a large part in missed opportunities and lost revenue. The revenue cycle becomes seamless with AI and automation in healthcare claims management. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI and automation-driven claims management software offers healthcare organizations a way to achieve these goals. Contact Experian Health today to prevent healthcare claim denials and improve your claims management process with AI Advantage and other denial management solutions.

Patients increasingly expect convenience and efficiency in all aspects of their lives, including healthcare. A study by Experian Health shows that 89% want the ability to schedule appointments anytime via online or mobile tools. The same survey showed providers are listening, with 63% offering self-scheduling and another 16% planning to go live with these tools in six months. That's good news for everyone, and not just because patients say they want more digital tools to manage their healthcare. Online scheduling addresses patient expectations by offering a range of benefits that traditional scheduling methods cannot match. However, these benefits aren't just for patients; healthcare providers that deploy online patient scheduling software experience four impressive benefits with a direct impact on their revenue cycle. What is online patient scheduling software? Online patient scheduling software is a digital tool designed to facilitate the appointment booking process for healthcare providers and their patients. This patient access technology replaces traditional over-the-phone scheduling methods with an efficient and user-friendly online system. The key features of patient digital scheduling platforms include: 24/7 appointment booking: Patients can schedule appointments at any time, day or night, providing flexibility and convenience that traditional methods cannot offer. Automated reminders: The software sends automatic reminders via email or SMS to reduce the likelihood of missed appointments. Real-time availability: Patients can view and select available time slots in real-time, ensuring they can find appointments that fit their schedules. Calendar integration: The software integrates with the provider's existing calendar systems to ensure that all appointments are accurately tracked and managed. Customizable scheduling: Healthcare providers can customize the software to reflect their specific scheduling rules, such as appointment types, durations, and provider availability. Manual scheduling frustrates patients and providers. Online patient scheduling allows patients to regain control while increasing their engagement in managing their health. Why do patients prefer online scheduling? Patients want online scheduling software because it aligns with their desire for convenience, efficiency, and control over their healthcare experience. One of the primary reasons to use online scheduling software is its round-the-clock availability. Patients can book appointments without office-hour restrictions. Online scheduling software allows patients to select time slots best suited to their schedules, minimizing the time spent waiting on hold during phone calls or in busy waiting rooms. Patients can easily see and compare availability, making planning their visits easier around personal and professional commitments. It also makes canceling or rescheduling appointments less of a hassle. One common issue patients face is forgetting about their appointments. Online scheduling software often includes automated reminders and confirmations via email or SMS, helping patients remember their upcoming visits. Some patients may also feel uncomfortable discussing their medical issues over the phone or in person at the front desk. Online scheduling offers a more private and discreet way to book appointments, allowing patients to select services without disclosing personal information to multiple people. Bringing digital efficiencies to healthcare scheduling leads to a more positive patient experience. One study showed that 28% of patients say care access has improved over the past year, even as more providers adopt these new technologies. But it's not just patients who benefit from online patient scheduling software. There are plenty of incentives for healthcare providers to adopt these tools. Healthcare providers benefit from online patient scheduling By adopting this technology, healthcare providers can streamline operations, improve patient satisfaction, and ultimately deliver higher-quality care. Experian Health offers online patient scheduling software that meets the needs of patients while benefiting providers. For example, Indiana University Health (IU Health) deployed the software across 16 hospitals and the largest network of physicians in the state. The organization leveraged the solution to increase patient volumes with minimal staff training, improving patient utilization by 114% within the first year. Today, four employees can handle patient scheduling for up to eight service lines. An unexpected benefit was the increase in referral management; the software enabled 600 monthly referral appointments, helping to generate new revenue for the system. These results are typical; most providers find the benefits of online patient scheduling software include: Reduced staff training time Improves the scheduling process for patients and providers Decreases patient no-shows Increases patient volumes and revenue Speeds up staff training One of the most significant challenges in any healthcare setting is training new staff quickly and effectively. Getting new staff up to speed rapidly is essential when severe staffing shortages are the norm. Experian Health's online patient scheduling software simplifies training. Its user-friendly interface and intuitive design reduce the learning curve for new employees to about an hour. The software provides guided workflows and real-time assistance, translating to less time spent on training and more time focused on patient care. Streamlines scheduling time Traditional scheduling methods can be time-consuming and prone to errors; 62% of providers say chronic staffing shortages exacerbate the problem. Online scheduling streamlines the entire process, cutting scheduling time in half over traditional methods. By allowing patients to book appointments online, the software reduces the back-and-forth communication typically required for scheduling. Automated reminders and confirmations ensure efficient appointment management. The calendar integration feature allows real-time updates and availability checks, providing a convenient booking process that enhances the patient experience. Improves patient no-show rates Patient no-shows can be a significant issue for healthcare providers, leading to lost revenue and wasted time. Experian Health's online scheduling software tackles this problem head-on. The software includes automated email or SMS appointment reminders, significantly reducing the likelihood of patients forgetting their appointments. Additionally, the ease of rescheduling allows patients to adjust their appointments without the hassle, further decreasing no-show rates. By keeping patients informed and engaged, the software helps ensure they attend their scheduled appointments, improving the clinic's efficiency and patient satisfaction. Josh Brown, Program Manager for Provider Match at IU Health, stated, “We've seen a reduction in no-shows and an increase in patient engagement. By leveraging technology and data analysis, the guided scheduling platform has helped deliver better care more efficiently and effectively.” Increases patient volumes and revenue Online patient scheduling directly contributes to increased patient volumes by improving scheduling efficiency and reducing no-show rates. More patients can schedule in less time, and the reduction in no-shows means fewer appointment slots go unused. The convenience of online scheduling can attract new patients who prefer digital interactions over traditional phone calls. These benefits lead to higher patient volumes and increased revenue for the healthcare practice. Today's digitally-savvy healthcare consumers require a different approach to scheduling services. Online patient scheduling offers them the convenience of DIY appointment setting and has some surprising benefits for healthcare providers, too, making these solutions a win for everyone. Ready to make the move to online scheduling? Contact Experian Health to get started! Improve patient scheduling Contact us

With over $220 billion in medical debt, patients in the U.S. are burdened by substantial financial obligations. These numbers also distress healthcare providers, who face cash flow and other operational challenges stemming from unpaid patient bills—and debt collection can further strain the relationship between care providers and patients. An efficient financial clearance process at the beginning of each patient encounter can benefit the entire system. But what is healthcare financial clearance and how can providers achieve it? What is financial clearance in healthcare? Financial clearance in healthcare is an administrative process that ensures patients understand their financial obligations before service delivery. It's often a manual workflow that involves verifying insurance coverage, estimating out-of-pocket costs, and discussing payment options or plans. The main objectives of financial clearance in healthcare are to prevent unexpected financial burdens for the patient, reduce the risk of unpaid medical bills for the provider, and streamline billing and payment. Common challenges with healthcare financial clearance Complex insurance policies, inaccurate or incomplete patient information, and lack of patient understanding of their own policy requirements are just a few of the challenges healthcare providers face in financial clearance. Not all healthcare providers have access to advanced technology or automated systems to streamline financial clearance, leading to reliance on manual processes that are prone to errors. Determining eligibility for financial assistance involves navigating complex criteria, which include assessing individual income, household size, savings, and medical requirements. When patients need help understanding their policy requirements, the educational burden often rests on the healthcare provider. Traditional manual methods of collecting and analyzing this data are prone to inefficiencies and inaccuracies, leading to missed opportunities to provide necessary financial support to patients. This makes the financial clearance process even more time-consuming, requiring significant administrative effort to verify insurance details, secure authorizations, and communicate with patients and insurers. Verifying a patient's insurance details during financial clearance ensures that the provider has the correct information about the patient's coverage, reducing the risk of denials due to eligibility issues. Financial clearance involves confirming that the patient is eligible for the services under their insurance plan. If eligibility is not verified beforehand, providers may deliver services that are not covered, leading to denials. Financial clearance also involves estimating the patient's out-of-pocket costs and ensuring the patient understands their financial responsibility. This process helps reduce denials related to unmet deductibles or co-payments, as patients are informed about their financial obligations upfront. Enhancing the healthcare financial clearance process improves revenue cycle management and significantly boosts patient satisfaction. As reimbursement denials continue to rise, healthcare providers have a vested financial interest in minimizing the financial uncertainties patients face early on in their healthcare journey. The use of technology to automate many of these manual processes allows healthcare providers to focus on minimizing financial uncertainty for patients, thereby enhancing their overall experience. Improve revenue cycle with automated healthcare financial clearance Healthcare providers can use technology to understand patient payment challenges and recommend the best financial pathway during the registration process. Providers like UC Health in Colorado leveraged Experian Health's Patient Financial Clearance software to write off $26 million in charity care. The technology integrates cleanly with the provider's electronic health record (EHR) to lessen the back-and-forth between systems during patient registration. Identifying the patients who need financial assistance upfront lessens the time spent pursuing bad debt and connects those who qualify for financial assistance with the right programs. Experian Health's Patient Financial Clearance solution fosters clear communication between the healthcare provider and the patient regarding coverage, costs, and payment expectations. This transparency helps in addressing potential issues that could lead to denials before they occur. Automation reduces bad debt and improves the patient experience Technology answers the question of 'what is financial clearance in healthcare?' with outcomes that include higher patient satisfaction and a better bottom line. Patient Financial Clearance automates screening to determine financial and clinical eligibility for each person at the first point of service. It answers critical questions such as: Does the patient qualify for financial assistance? What constitutes a realistic patient payment plan? Notably, the software helps set the tone for the patient intake specialist, approaching payment terms proactively and empowering everyone to take on their financial responsibilities early in the care delivery process. Patient Financial Clearance automates and streamlines manual workflows to optimize the revenue cycle. For example, this software can: Automate screening prior to service or at the point-of-service to determine if patients qualify for financial assistance, Medicaid, or other assistance programs, without relying on patients for information Leverage Experian’s comprehensive data and analytics capabilities to calculate the patient’s optimal payment plan amount based on the patient’s unique financial situation Predict propensity to pay using Experian’s proprietary Healthcare Payment Risk Score The benefits of Patient Financial Clearance for providers include: Improved point-of-service collections Lowered bad debt write-offs Increased staff productivity IRS 501(r) compliance Improved patient and staff experience For patients, Experian Health’s Self-Service Patient Financial Clearance option enables patients to conveniently complete eligibility checks at their own pace. Through a mobile and web-based platform, patients can submit screening forms and upload necessary documents, receiving real-time updates without the need to contact their healthcare providers. All information is securely stored, allowing staff to access application statuses as required. Automating financial clearance in healthcare transforms an unwieldy process into an efficient way to manage the delicate relationship between providers and patients. Technology can free up intake specialists to concentrate on creating a better patient experience and eliminate the frustrations surrounding collecting payment after the service is complete. Learn more about how Patient Financial Clearance can help healthcare organizations reduce bad debt by automating the patient financial assistance process.