First Pst after migration to Cloud in Health care Blog

Prior authorizations ensure that patients only receive care that is medically necessary, evidence-based and cost-effective. The process is a built-in safety net to prevent over-prescription of drugs and services, avoid duplication of tests, and make sure that ongoing treatments are actually helping the patient. At least, that's the goal. Many providers and patients tell a different story. Too often these well-intentioned mechanisms morph into paper-based barriers to care that do more harm than good in the long term. According to the American Medical Association (AMA), nine out of ten physicians have seen prior authorizations have a negative impact on patient outcomes, while a third have seen authorizations lead to a serious adverse medical event. A major part of the problem is the growing administrative burden. Processing submissions manually is time-consuming and error-prone – and even more challenging in the context of staffing shortages. Automated prior authorizations can alleviate the pressure and help providers deliver care to the highest possible standards. How prior authorizations can obstruct patient access and treatment Health insurers demand that providers seek prior authorization for certain treatments and procedures before they will agree to cover the costs under the patient's plan. If the request does not meet the payer's specific rules and criteria, authorization will not be given, and financial responsibility will fall to the patient. If the patient can't pay, the unsettled sums will find their place in the accounts receivable ledger, eventually written off as bad debt. To avoid this scenario, patients and providers may decide against the proposed care plan. Findings in the AMA survey suggest that eight out of ten physicians had seen patients abandon treatment because of prior authorizations. Even where pre-authorizations are eventually approved, the lengthy administrative process to determine whether services and providers are covered can still delay treatment. Such delays cause the patient's medical situation to worsen, entailing more invasive and costly treatment later. This overutilization of services is clearly at odds with the stated purpose of prior authorizations and the 'triple aim' in healthcare. Manual prior authorizations exacerbate delays in patient care The problem is compounded by the fact that many providers rely on manual processes to manage prior authorizations. But with payer policies changing all the time, it's hard for providers to keep up and ensure submissions are accurate. Some procedures need to be approved under one health plan, but not under another, so it's easy for some to slip through unapproved and wreak havoc later. This is especially worrying for patients with more complex and chronic conditions, who require multiple services from multiple providers. Paper-based processes can be painfully slow, causing bottlenecks in patient care and errors that result in instant rejections when the submission is finally processed. There's an urgent need for a more efficient approach. Automated prior authorizations can reduce delays in patient care Recognizing the need for reform, in December 2022, the Centers for Medicare and Medicaid Services (CMS) proposed a new federal rule that would streamline the prior authorization process for Medicare Advantage plans, Medicaid and Children's Health Insurance Program managed care plans, and state and Marketplace coverage. If the rule comes into effect, it will require health plans to respond to urgent prior authorization requests within 72 hours, and to non-urgent requests within seven days. Affected payers would need to implement standardized interfaces and automations to improve data interoperability. Further information on this rule may is expected toward the end of 2023. Several states are making their own arrangements to regulate prior authorizations to help alleviate the administrative burden on providers, though these efforts have been described as a “mixed bag.” Ultimately, improving the prior authorization process comes down to making sure request documentation is filled out and submitted as accurately and as quickly as possible. The most effective way to do that is with the help of automated prior authorization software. Automated prior authorizations alleviate staffing challenges Providers are finding increasing value in prior authorization automations as they deal with ongoing staff shortages. In a staffing survey by Experian Health in August 2023, 37% of providers said their prior authorization processes were affected by staffing shortages. Neeraj Joshi, Director of Product Management at Experian Health, says that relying on manual processes in these circumstances is increasingly untenable: “For many providers, there simply aren't enough staff to manage the growing burden of prior authorizations. Remaining staff are stressed out, which unfortunately can lead to mistakes and bottlenecks. It creates a poor patient and staff experience. Automating prior authorizations eases the pressure by allowing more authorizations to be processed in less time and making it simpler for staff to track and follow-up inquiries. Not only does a faster approval process mean patients get care without delay, but it also reduces the risk of denied claims.” Read more about the key benefits of automating prior authorizations. How it works: key features of prior authorization software Experian Health's prior authorization solution, Authorizations, automates inquiries and submissions without user involvement. The software auto-fills payer data based on current requirements, guiding users to any tasks that need manual attention using an exceptions-based workflow. It proactively generates status updates so staff can see at a glance whether a request is pending, denied or authorized. These integrated automations increase operational efficiency by accelerating the authorizations process, minimizing unnecessary manual work, and reducing the risk of denials. Patients get the care they need, and providers get greater revenue cycle predictability. Overview of prior authorization platform features Authorizations accesses current prior authorization requirements in real-time using Knowledgebase, Experian Health's repository for national payer rules and criteria. Users can add local rules and updates as needed. Users are directed to the correct payer portal to make a submission for the procedure in question. Documents can be submitted to payers without electronic portals using integrated faxing. Automated inquiries give users an instant view of whether a submission is pending, denied or authorized. Dynamic work queues alert users to any tasks that need their attention. Authorization status, number and validity dates can automatically be posted back to health information and practice management systems. Images of payer responses can be stored securely using the integrated document imaging system. The software compares and reconciles authorized and delivered procedures. It flags any variances to staff can intervene to proactively prevent denials and appeals. Better communication will lead to better clinical outcomes Automations may not be able to resolve the conflicting perspectives of over-burdened providers and cost-conscious payers, but they can take the sting out of the administrative process. Prior authorization software smooths out the exchange of data so payers, providers and patients can communicate more effectively. With better communication, come better clinical outcomes – and that's in everyone's interests. A single-vendor solution extends this advantage internally, too. Integrating proven, cost-effective and compliant solutions with existing workflows can help front-end and back-office teams work together as efficiently possible. Experian Health's Authorizations solution integrates seamlessly with eCare NEXT®, leveraging automations in patient management and revenue cycle workflows, so providers can focus on their core competence: providing high-quality care to patients. Find out more about how Experian Health's automated prior authorizations help providers optimize patient care.

The complexities of healthcare claims management are a widespread, costly issue. While the American Medical Association (AMA) blames prior-authorizations as the main cause, it's clear that hospitals struggle to collect on predicted revenues often for months after they provide the service. It's not a sustainable situation as the costs of care delivery increase, staffing shortages drive up labor overhead, and inflationary pressures stretch healthcare providers to their breaking point. There is no question the claims denial process is ripe for innovation – and that's where artificial intelligence (AI) comes in. A 2022 Experian Health survey shows over one-half of healthcare providers increasingly turn to AI-driven healthcare claims management software to reduce claim denials. Tom Bonner, Principal Product Manager at Experian Health, says, “Adding AI in claims processing cuts denials significantly. 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.” Common reasons for medical claim denials Revenue cycle leaders place healthcare claims management as their number one issue in 2023. Experian Health's survey showed the three most common reasons for medical claim denials were: Needs more data and analytics to identify submission issues. Manual claims processing and a lack of automation. Insufficient training for staff. The sheer volume of changes to CPT codes is another issue affecting HCM or healthcare claims management. Experian Health identified more than 100,000 payer policy changes from March 2020 to March 2022. These shifts necessitate a never-ending cyclic need to train new staff, increase the risk of claim rejections, and slow down manual workflows in healthcare claims denials management. How can healthcare providers improve claims processing and overcome these challenges? Real-life ROI with AI in claims processing AI in claims processing solves these and other common revenue cycle problems. This technology is the innovation healthcare providers need to reduce denials and increase cash flow. AI can help at every point in the revenue cycle continuum, from improving the accuracy of payer data upfront to ensuring a clean claim and even targeting denials that yield the highest return. What real-life lessons does AI in claims management teach healthcare providers? Experian Health's new AI-powered solution includes AI Advantage™ – Predictive Denials and AI Advantage™ – Denial Triage, which is geared towards helping healthcare organizations reduce claim denials. Within six months of using AI Advantage, Schneck Medical Center reduced denials by an average of 4.6% each month. Claim corrections that formerly took up to 15 minutes to correct cut to just under five minutes. Even smaller ambulatory clinics like Summit Medical Group Oregon benefit from automating healthcare claims management. After implementing Experian Health's claims management software, the provider saw an immediate reduction in claims denials. Today, they boast a 92 percent clean primary claims rate. These results are typical across healthcare organizations that implement AI in claims processing. But what does the software do to clean up the complexities of claims management processing? How to avoid claim denials with AI In 2022, Experian Health surveyed 200 revenue cycle leaders around the country and identified technology shortfalls as a significant contributor to claims denials: 62% reported they lacked the data analytics to identify submission issues. 61% said manual processes and a lack of automation were significant problems. 33% suggested their healthcare claims management software was outdated or inadequate. Healthcare claims management upgraded with the inception of AI-driven healthcare claims management software. The benefits of these tools lie in their ability 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 also assist in identifying inaccurate claims, improving claims processing accuracy and revenue cycle management. By using automation and AI together, 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 claims processing maximizes the benefits of automation for better claims processing, better customer experiences, and a better bottom line for healthcare providers.” How does healthcare claims denial management software work to improve the revenue cycle? AI identifies and prioritizes high-value claims after denial AI in claims processing goes beyond automating process-driven manual tasks. It also removes the guesswork from healthcare claims management. For example, staff is often left guessing which denied claims are the low-hanging fruit that they should process first. Staff must decide which denied claims have a higher likelihood of reimbursement and a higher dollar value to maximize their efficiency. Why would healthcare providers leave these high-value/high-return claims to a manual “best guess” estimation process? Yet that is standard operating procedure in most hospitals. AI in claims processing identifies and prioritizes high-value claims automatically. Experian Health's AI Advantage – Denial Triage goes to work when a claim is denied by identifying and intelligently segmenting denials based on potential value so that staff focuses on resubmissions with the most significant bottom line impact. This intelligent segmentation removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials. But the front-end work AI software completes during healthcare claims management may be even more valuable. AI can prevent claims denials from occurring at all. AI proactively stops claim denials from occurring AI Advantage – Predictive Denials uses AI to identify undocumented payer adjudication rules that may result in new denials. It identifies claims with a high likelihood of denial based on an organization's historical payment data and allows them to intervene before claim submission. Experian Health also has other automated solutions that help facilitate claims management. 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 also generates accurate adjudication reports within 24 to 72 hours to speed reimbursement. ClaimSource ranked #1 in Best in KLAS 2023, precisely 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. AI optimizes the claims process Another Experian Health solution, Enhanced Claim Status improves cash flow by responding early and accurately to denied transactions. This solution uses RPA to give 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 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 module to help eliminate manual processes, allowing providers to optimize claims submission and maximize cash flow. How to reduce claim denials with AI and Experian Health There's no question that healthcare claims denials management is an unwieldy, time-consuming, and ever-changing process. Reimbursement is complex on its own, but human error plays a large part in missed opportunities and lost revenue. With AI in healthcare claims management, the revenue cycle streamlines and transforms. Any healthcare provider seeking faster reimbursement and a better bottom line knows that improving claims management is critical to better cash flow. AI healthcare claims management software offers provider organizations a way to achieve these goals. Contact Experian Health today to reduce claim denials and improve your claims management process with AI Advantage.

As retail and technology companies make moves in healthcare, existing providers must find new ways to attract and retain patients. Offering personalized patient payment plans is one way to meet evolving consumer demands and hold on to the competitive edge. The best part of this strategy? Providers can use data they already hold to deliver convenient and compassionate collections. Digital disruptors are driving a consumer-centric approach to healthcare payments Having transformed consumer expectations over the last decade, digital technology giants – along with a new generation of start-ups – are now actively pursuing a share of the multi-billion-dollar US healthcare market. Concierge medicine, on-demand virtual health and other personalized services are solidifying consumer expectations of flexibility, convenience and control. While consumers have more choice, they're also paying more for healthcare. Inflation-weary consumers are apprehensive about rising costs, and many report frustrations with healthcare billing and payment processes. According to a 2022 Gallup poll, nearly four in ten patients postponed medical care because of cost concerns. This tension between demand for choice and concerns about affordability leaves the sector vulnerable to disruption by players that offer alternative payment models that make healthcare more affordable for consumers, while making it easier to pay for care. Creating a more consumer-friendly approach to patient collections is essential for profitability. 1 in 10 patients use payment plans to manage the cost of care Research by Experian Health and PYMNTs shows that patients welcome payment plans to spread out the cost of care. One in ten patients had used a payment plan to pay for their most recent doctor's visit. Nearly three in ten older patients used a payment plan after receiving an unexpected bill. Unsurprisingly, those on lower incomes were most likely to need payment plans. Experian Health's State of Patient Access survey 2023 emphasized patients' desire for more flexible and transparent payment options, including pre-service estimates, payment plans and digital payment methods. Providers see the benefits too: around two-thirds of providers said their organization understands patients' unique financial situations and offers payment plans and financial assistance where appropriate. Using data to tailor patient payment plans For payment plans to work effectively, personalization is non-negotiable. Too often, payment plans apply a generic “one size fits all” formula to patient accounts, regardless of payment history, financial situation or other key indicators of the patient's ability to pay. This runs the risk of delivering a poor consumer experience while doing little to reduce patient bad debt. With a data-driven approach, healthcare organizations can identify the optimal plan for each patient. For example, PatientSimple® uses Experian Health's proprietary data and analytics to assess each patient's propensity to pay and guide them to the most appropriate financial pathway. A self-service portal gives patients a convenient way to generate estimates and consider different pricing plans, so they can make a more informed and confident decision about how to pay their bills. It also supports staff to have more compassionate financial conversations with patients. Similarly, Patient Financial Advisor and Patient Estimates give patients upfront, accurate estimates of what they're likely to owe, drawing on current chargemaster lists, payer contracts and the patient's insurance data. Together with payment plans, these estimates help patients avoid unexpected bills, so they have a more positive payment experience and are less likely to miss payments. A third tactic is to make it as easy as possible for patients to pay. Self-service and contactless payment options remove friction from the payment process, so patients are more inclined to pay promptly where they can. The patient's account data can be securely auto-populated into payment tools so they can pay and go with minimal fuss. Stay ahead of competitors by creating patient-friendly experiences As healthcare evolves, healthcare organizations need to develop strategies to remain competitive while still delivering compassionate care. Personalized patient payment plans are one way to strike that balance. Not only do they give patients the flexibility and convenience they’re looking for, but providers can also use existing data to tailor plans that benefit both company and customers alike. Alex Harwitz, VP of Product, Digital Front Door, at Experian Health, says these tools can help providers stay competitive as patients are exposed to a growing range of consumer-friendly healthcare services: “The move towards more patient friendly online experiences is a catalyst for improved price transparency. The challenge for providers is to adapt to shifting consumer needs while managing their resources wisely. But there's a major opportunity for providers to use data they already hold to help patients figure out the best financial pathway. Putting patients first is a sure-fire strategy to see patient satisfaction and patient collections rise in parallel.” Find out how healthcare organizations can remain profitable in an increasingly competitive market with personalized patient payment plans and patient payment solutions.