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As discussed in part one of this blog series, technology such as patient portals are changing the way physicians are interacting with patients and how those patients access their medical information. An article in USA Today quotes the American Academy of Family Physicians on usage: 41% of family practice physicians use portals for secure messaging Another 35% use them for patient education About one-third use them for prescribing medications and scheduling appointments While intuitively it might seem that online interactions would distance physicians and patients, the reverse is actually true. Researchers found that patients who had online access to their physicians and other healthcare professionals increased their use of in-person and telephone clinical services, according to a study published in The Journal of the American Medical Association. Increases in patient engagement can carry over into patient billing portals. Take Cincinnati Children’s Hospital Medical Center (CCHMC), for example. The organization decided to update its patient billing portal two years ago in the hopes that a better interface and more functionality would increase the number of families using the portal. With only a one-time notice in a paper statement, CCHMC saw adoption rates soar more than tenfold in the first year after implementing the new platform. CCHMC, which is consistently ranked in the nation’s top five children’s hospitals, also experienced an increase in collections of 10-15%, and a five-fold increase of online payments, up from $200,000/month to $1 million/month. The patient-friendly portal now has more than 22,000 families using its self-service functions. The portal gives users 24/7 online account management, along with the ability to schedule appointments, pay bills and access lab results. Families now have anytime, anywhere access to their account, an important benefit for busy families trying to cope with a sick child. In conjunction with the online portal modernization, CCHMC also gave its printed patient statements a facelift. Not only did patients find the previous multi-page statements confusing, it had become increasingly expensive and time consuming to make even minor information changes and updates. Altering something as simple as a phone number or office hours could cost thousands of dollars in custom programming fees. The adoption of a new patient statement solution has given CCHMC the ability to make statement changes in house, eliminating custom programming while also reducing mailing expenses. In the first year, CCHMC saved $70,000 on their monthly invoicing due to lower printing and mailing costs, reducing the statement size from two pages to one and receiving discounts on postage. With patient experience and engagement a top priority for providers, it’s critical to consider a similar approach that works for your organization—an approach that will help patients be more active participants in their health, as well as support your clinical and financial goals. CCHMC will discuss its experiences with patient engagement, administrative savings and lessons learned at our January 28 Webinar, “Improving the Patient Billing Experience Through Online Customer Self-Service.” Register now to attend.
Rudyard Kipling famously wrote, “Oh, East is East, and West is West, and never the twain shall meet.” That was once true of care delivery and medical payments; they were two separate departments encountered at different stages during a physician or hospital visit, and each was siloed to the activities of the other. Today, patients are avid participants in their care and are more engaged and concerned with where their healthcare dollars are spent. With that in mind, savvy providers are collaborating with patients not only on a clinical level, but also on the financial side to better navigate their options. This new approach gives patients the power to make informed financial decisions about their care, with discussions taking place prior to treatment, rather than after when an unexpected bill or lack of understanding around financial obligations can negatively impact a patient’s overall perception of their care and the organization itself. While it’s no surprise that patients are taking on greater financial responsibility for their healthcare costs due in large part to the rapid rise of high-deductible health plans, the statistics are overwhelming. In 2006, only 55 percent of covered workers had an annual deductible, which averaged $584. In 2014, according to the Kaiser Family Foundation, that deductible has more than doubled to an average of $1,217 for 80 percent of the covered workforce. When you consider that slightly over half of covered workers have an annual out-of-pocket maximum of $3,000 or more, that creates a gap that providers can’t ignore for the sake of their fiscal health, or that of their patients. At the heart of achieving better patient engagement on the financial side is accurate, real-time information. Advanced technology gives providers the ability to provide patients with a more comprehensive picture of financial information and to present them with financial options that fit their needs. Three key steps to achieving higher payments and better patient satisfaction include: 1) Be proactive – Talking to patients prior to receiving care not only results in higher patient engagement and satisfaction, it also substantially increases the amount providers can expect to collect. For example, showing online full-disclosure of billing data builds trust among patients. 2) Provide accurate estimates – Patients deserve the right to make informed decisions based upon the cost of care. For example, providers should be able to quickly – and easily – review expected costs and explain insurance coverage. Offering patients tools, such as the ability to request a real-time estimate online, gives them more control over the financial side of their healthcare. 3) Offer choices – Payment plans designed in cooperation with patients, such as the ability to set up automatic payments, not only empowers them, it improves payments and reduces administration burdens. Implementing these initiatives creates a more informed patient, which leads to a positive care experience and eases financial stressors. Patients are able to make educated choices and, if necessary, structure a payment plan that meets their needs or identify potential financial assistance programs. Providers also see benefits, such as increased patient loyalty as well as an improved revenue cycle and decreased administrative burdens when it comes to collections and follow up. Mr. East, meet Ms. West. By integrating the clinical and financial sides of healthcare, patients are more engaged with their care, leading to better health for the patient and improved financial outcomes for providers.
The evolution from paper to online medical records is an opportunity to engage patients more fully in their care while making healthcare organizations more efficient. However, while patients enjoy the convenience of self-service access to all of their medical information, the portals offer cybercriminals a one-stop-shop for identity theft as well. According to Identity Theft Resource Center in San Diego, medical identity theft is the fastest growing type of identity theft, increasing at 32% annually. In fact, healthcare-related data breaches are already 10 times more frequent than data breaches in the financial services sector. And unlike stolen credit card information, which is often detected within a few transactions, medical identity theft often goes undetected for over a year. The comprehensive data contained in patient portals is especially lucrative to fraudsters, demanding a premium price in the underground market. While a stolen credit card number may sell for a dollar, a full set of medical records can command hundreds of dollars. The breadth of data within a patient portal offers fraudsters multiple opportunities to “cash in.” Compounding the problem is the level of detail presented on patient portals, often including unmasked insurance IDs, full images of patients’ insurance cards, problem lists, prescription histories. Stolen medical identities are used by criminals in two ways: obtaining medical care under the victim’s identity and using the identities to fraudulently bill for services or durable goods, which were never delivered. Problem lists, which are a mandated component of patient portals, are particularly useful to criminals, because they allow classification of each victim by the type of fraud which their identity could support. The problem lists typically use standard terminology, which makes them particularly useful for classification purposes. Using malicious software, criminals can search the lists for “key words” describing conditions that demand specific types of services or durable goods. This targeted approach would make fraud more personalized to the victim’s profile and harder to detect. Most patient portals use simple password protection, which can be easily captured by key-logging malware. This type of malware lays dormant on the victim’s machine, waiting for the victim to log into a patient portal site. When the patient logs in, the malware wakes up and captures the victim’s username and password. Using the stolen credentials, the criminals can get into the site, and once in can collect extensive information about the victim. Medical identity theft has severe consequences for both patients and providers. Patients are faced with the financial costs of covering fraudulent bills and medical costs stemming from treatment of other individuals. Comingling of the victim’s and the criminal’s medical records can also put the patient in life-threatening situations if treated or diagnosed incorrectly. Providers face steep financial costs from retribution payments and HIPAA violation fees up to $1.5M per violation, however arguably the most significant consequence they face is damage to reputation. Complicating matters is the fact that security measures cannot be so onerous that they dampen consumer adoption. Towards that end, use of covert technologies to analyze the identities and devices enrolling into a patient portal or logging in to it can increase security without impacting user experience. Precise ID® with FraudNet for healthcare portals provides healthcare organizations with a way to confidently authenticate patients and reduce risk during enrollment and ongoing access to healthcare portals. It does so in a streamlined manner without burdening patients with increased wait times and complexities. Together, these solutions identify fraud, authenticate patients and validate devices – all in a single platform. To learn more, view Experian Health’s complimentary on-demand webinar, “The Hidden Risks of Healthcare Portals,” or download the new white paper, “The Pitfalls of Healthcare Portals,” where we outline why your portal may be more vulnerable than you think.
Experian Health is very pleased to announce that we've ranked #1 in the 2025 Best in KLAS: Software & Services report, for our Contract Manager and Contract Analysis product, for the third consecutive year. Contract Manager, when paired with Contract Analysis, empowers healthcare providers by ensuring payers comply with contract terms, identifying and recovering underpayments, and arming them with real claims data to negotiate contracts. This enables providers to negotiate more favorable terms and maintain financial stability. Clarissa Riggins, Chief Product Officer at Experian Health, says, “In the ever-evolving healthcare landscape, our Contract Manager solution has once again been recognized as the #1 Revenue Cycle Management tool by KLAS for the third consecutive year. This prestigious ranking underscores the significant value our solution delivers to our clients by identifying underpayments and facilitating revenue recovery. We are honored to continue supporting our clients with innovative solutions that drive financial success and operational efficiency.” Learn more about how Contract Manager and Contract Analysis can help your healthcare organization validate reimbursement accuracy, recover underpayments and boost revenue. Learn more Contact us
Experian Health's State of Claims 2024 report reveals a worrying trend in healthcare claim denials, with nearly three-quarters of survey respondents reporting a rise. Around four in ten say claims are denied 10% of the time, with one in ten seeing denial rates above 15%. Denials at this scale, driven by various claim denial reasons, represent billions of dollars in lost or delayed reimbursements, so it's no wonder that reducing health insurance claim denials tops healthcare providers' “must-fix” list. However, despite being highly motivated to resolve the challenge, many organizations need more support to overcome operational roadblocks. Prior authorizations are taking longer to come through. Payer policy changes are more frequent. Patient information is increasingly inaccurate. For 65% of respondents, submitting clean claims is more complex than before the pandemic. With some wrangling more than three technological solutions and others lacking confidence about using automation and AI, providers seem to be struggling to find the sweet spot when tackling denials. This article looks at the reasons for increased claim denials, as well as how automation and artificial intelligence (AI) can help healthcare providers overcome these obstacles to increase operational efficiency and improve cash flow. Major operational challenges leading to increased claim denials Clarissa Riggins, Chief Product Officer at Experian Health, says that many providers are increasingly concerned that payers won't reimburse costs as denial rates increase, when discussing the State of Claims 2024 report. These concerns reflect operational challenges, including difficulty keeping track of pre-authorization requirements, inability to keep up with rapidly changing payer policies and inadequate front-end data collection. While staffing shortages are not among the top three claim denial reasons as they were last year, they are a continuing drag on efficiency for 43% of providers. Burdened by limited resources, these revenue cycle teams are more likely to make avoidable errors during claim submission—a problem that is affecting the four in ten providers who say they have limited resources to cross-check claims for errors. Riggins suggests that healthcare organizations look to technology to close the claims gap: “We had hoped to see a decrease in claim denials from our previous survey, but it's clear these significant challenges are continuing, adding immense pressure on providers to improve their revenue cycle management processes. This growing crisis is a sign that traditional approaches are no longer enough, and providers should adopt more proactive strategies and the latest technology to navigate this volatility.” Top reasons for healthcare claim denials Here are the top three claim denial reasons and how automation and AI can solve them: 1. Missing or inaccurate claims data Missing or inaccurate claims data is the number one operational challenge responsible for the increase in medical billing claim denials – among the top three challenges for 46% of respondents in the State of Claims 2024 survey. Submitting clean claims relies on getting data right the first time. It calls for speed and efficiency, which is impossible with slow, error-prone manual systems. Yet almost half of the respondents say their organizations are reviewing claims manually. While 54% of respondents believe their technology is sufficient to meet claims management demands, increasing errors and rising denials tell a different story. Revenue cycle leaders who embrace automation in their claims submission and denial prevention strategy set themselves up for smoother operations and a boost to the bottom line. Without the right automation to increase the speed and accuracy of claim submissions, valuable staff time and effort are wasted on manually processing error-prone claims, increasing the likelihood of denial. The lack of automation also places unnecessary strain on staff, diverting their attention from more complex claims issues. 2. Prior authorizations Claim denials often stem from poor communication between payer and provider systems, with the prior authorization process as a prime example. The process requires providers to seek agreement from the payer to cover a service or item before it is administered to the patient. Failure to do so results in the claim for that treatment being denied. Unfortunately, obtaining prior authorizations is not always straightforward; sometimes, the patient's treatment must begin before the authorization process is concluded. Other times, the authorization only covers certain aspects of the treatment. Not only is the prior authorization process complex, but it is also costly, laborious, and time-consuming to navigate successfully. According to the 2023 AMA Prior Authorization Physician Survey, physicians and their staff spend 12 hours per week completing prior authorizations, with almost all reporting physician burnout as a result. Providers must stay on top of frequent changes to payer policies, and staff must use multiple payer portals to track authorization requests. Unsurprisingly, authorizations are among the top three claim denial reasons for 36% of respondents in the State of Claims survey. As with any challenge involving digital systems “talking” to one another, authorizations are a great use case for automation. Automation can be used to check payer policy changes, alert staff when prior authorization is needed, gather relevant documentation, and review authorization requests for accuracy. This significantly reduces the burden on staff and minimizes the risk of claims being submitted without the necessary authorizations in place. Experian Health's Prior Authorizations technology automates authorization inquiries and checks requirements in real time. It uses AI to help users find and access the appropriate payer portal to speed up the authorization workflow. Users will have confidence that they're looking at the same account information and policy details as the payer, which means lengthy negotiations can be avoided. Staff also get accurate status updates on pending and denied submissions so they can take appropriate action and maximize reimbursement. 3. Inaccurate or incomplete patient data Even the slightest mistake or mismatch in a patient's name, address or insurance details can result in a denial, leading to payment delays and extra work for the staff. These denials are particularly frustrating because they should be avoidable. Automation can be used to pre-fill the patient's information before they arrive to avoid the errors that occur with manual input. This has the added benefit of accelerating registration. These solutions can also check for duplicate charges, missing fields and coding inaccuracies. For example, Claim Scrubber helps providers prepare error-free claims for processing by reviewing each line of the claim before it's submitted. ClaimSource® helps providers manage the entire claims cycle by creating custom work queues and automating claims processing to ensure that claims are clean the first time. Implementing technology to prevent claim denials The report details some of the strategies providers are using to try to reduce denials. These include upgrading existing claims process technology, automating or expanding patient portal claims reviews, and automating tracking of payer policy changes. More than half are motivated to adopt new technology to reduce manual input. This is exactly what Denial Workflow Manager is designed to do. It enables providers to track claim status and appeals and quickly identify those that need to be followed up on. It eliminates the need for manual review, while analysis and reporting give staff insights into the root causes of denials to optimize performance. This solution can be integrated with tools like Enhanced Claim Status, which sends automatic status requests based on the type of claim and specific payer timeframes. It generates accurate adjudication reports within 24-72 hours to accelerate the revenue cycle. The output is viewable in ClaimSource to streamline workflows and manage the claims process in a single online application. Automation and digital technology are also valuable counterweights to the shortage of qualified staff. While staffing shortages aren't as high on the list of concerns as in previous years, they remain a stubborn problem. By reducing the need for manual input, claims management can be accelerated while freeing staff to focus their attention where it matters most. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more AI solutions for reducing claim denials Healthcare organizations can get more bang for their buck from automation by integrating these solutions alongside AI. Interestingly, the survey suggests that providers have mixed feelings towards AI: 35% of providers say they want solutions that leverage more AI and machine learning, yet only 8% are actually using them. Current ClaimSource users might consider AI Advantage™, which uses AI and automation to generate real-time insights for a proactive approach to denial management. It helps providers combat claim denials from two angles: AI Advantage – Predictive Denials uses AI to identify undocumented payer adjudication rules that 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. AI Advantage – Denial Triage comes into play if a claim has been denied. This component uses advanced algorithms to identify and intelligently segment denials based on potential value so that organizations can focus on resubmissions that most impact their bottom line. Doing so removes the guesswork, alleviates staff burdens, and eliminates time spent on low-value denials. This solution complements existing claims management workflows to help providers expedite claims processing, reduce denials, and maximize revenue. Another AI-powered solution helps prevent denials on the front end: Patient Access Curator allows patient access teams to capture multiple data points in seconds. This solution solves the “bad data” problem, using AI and robotic process automation to run checks for eligibility, coordination of benefits, Medicare Beneficiary Identifier, demographics and coverage discovery with a single click. The financial impact of denials and the ROI of technology Another paradoxical finding in the report is that while 47% of respondents see having AI technology as a competitive advantage, less than half say they'd be up for fully replacing their existing claims processing technology, even if presented with compelling ROI projections. Automation and AI can meaningfully impact the claims metrics that keep revenue cycle leaders awake at night – denial rates and clean claim rates being the top two. Patients also want to see improved performance when it comes to reducing denials. If healthcare organizations cannot offer a reliable, error-free system, they risk losing patients' trust and loyalty. Providers who demonstrate a well-managed claims system with swift and accurate results will inspire confidence and improve patient engagement. It's essential to assess how existing solutions perform against these metrics and implement upgraded solutions to deliver a more substantial ROI. AI and automation in practice How are Experian Health's clients using AI and automation to reduce claim denials? Here are a few examples: In only six months of adopting AI Advantage for claims processing and reducing claims denial, Schneck Medical Center saw denials fall by an average of 4.6% each month. In addition, the time needed to correct claims dropped from 15 to less than five minutes. The ambulatory clinic Summit Medical Group Oregon implemented Experian Health's claims management solutions, including Enhanced Claim Status and Claim Scrubber, to improve its registration and coding processes. These two solutions helped the team submit cleaner claims, resulting in a decrease in denials. As a result, the company now maintains a 92% primary clean claims rate. Another compelling example of the positive impact of technology on healthcare claims management is IU Health's experience with the all-in-one claim cycle management platform ClaimSource. With ClaimSource, IU Health managed the transmission of $632 million in claims in five days and processed $1.1 billion of claims backlog. Clients who have implemented Experian Health's Patient Access Curator have saved over $1 billion in denied claims, significantly boosting their bottom lines. Experian Health ranked #1 in Best In KLAS for our ClaimSource® claims management system – for the second consecutive year. Learn more Enhancing revenue cycles by addressing claim denial reasons By pinpointing the most common health insurance claim denial reasons and adopting automation and AI-driven solutions, providers can increase the first-pass clean claim rate, ramp up the likelihood of reimbursement, and reduce the overhead of reworking and resubmitting claims. Inevitably, hospitals will witness a surge in their financial performance. Contact us today to learn how data-driven claims management technology can help your organization reduce denied claims in healthcare and increase ROI. Improve claims management Contact us
The denial challenge is getting tougher. In Experian Health's latest State of Claims 2024 survey, almost three-quarters of healthcare administrators agree that claim denials are increasing. The majority also agree that difficulties with claims—like reimbursement times, errors, and payer policy changes—are becoming more common. It's no surprise that denial prevention is a priority for 84% of respondents. However, many organizations still focus on reactive strategies, like working harder with denial management teams or appealing claims once the denial comes through. These efforts have their place, but they only address the problem after it occurs. It's a time-consuming, costly and ultimately inefficient way to face the denial challenge overall. A better approach is to figure out how to prevent claim denials in the first place. This article looks at how to build a proactive denial prevention strategy using automation and artificial intelligence (AI), to streamline claims processing and nip denials in the bud. Understanding denial prevention in healthcare Preventing denials starts with understanding the “ins and outs” of the claims process, particularly payer requirements. Denials occur when a payer refuses to reimburse a provider for services rendered, often due to avoidable coding errors, missing documentation or procedural mistakes. When that happens, providers are left to rework the submission or look elsewhere – most likely to the patient – to fill the funding gap. Many are simply written off to bad debt. To avoid receiving an 835 file with the dreaded claim denial notice, providers must focus on the root causes of denials and get ahead of the pitfalls. The importance of claim denial prevention With denial rates exceeding pre-pandemic levels, 42% of survey respondents say the economy and declining consumer confidence make payer reimbursements more urgent. While financial stability is the obvious driver for getting claims right the first time, denial prevention also improves operational efficiency and reduces the billing and coding staff workload. Denials are frustrating for patients and staff. When claims are processed correctly the first time, providers avoid delays and billing complications and reduce patient stress over unexpected costs. Preventing denials is critical for maintaining trust and ensuring patients feel secure about their financial obligations. How to prevent claim denials Denial prevention strategies should start with addressing the underlying causes of denials. Here are five denial prevention strategies to consider: 1. Improve data accuracy from the start Garbage in, garbage out. If patient information, insurance eligibility, prior authorizations and billing codes are input incorrectly or missing altogether, providers will continue to submit error-filled claims that have no hope of being paid. Tools like Registration Accelerator and Patient Access Curator can verify relevant data for accuracy before claim submission and reduce the risk of denial. 2. Use AI and automation for efficiency If there was ever a case for using automation and artificial intelligence, it's in claim denial prevention. However, around half of providers are still using manual processes, leaving them playing catch-up to the payers who are already using AI to work at scale. Only 10% have automated the process, using AI to correct and resubmit claims. Tools like ClaimSource® can automate eligibility verification and coding, perform error checks before submissions and ensure claims meet payer requirements instantly. This cuts the time and effort wasted on manual processes, releasing staff to focus on activities that need human attention. 3. Automate pre-claim scrubbing to catch errors A great use case for automation is in providing an extra pair of eyes to pore over claims and catch common errors like missing data and wrong codes before submission. Experian Health's Claim Scrubber analyzes claims line by line to ensure that claims are submitted to payers and clearinghouses without errors, increase first-time pass rates and prevent rebilling. 4. Track performance for ongoing improvement Every denial prevention strategy should include monitoring and reporting. Tools that offer real-time tracking of key performance indicators such as denial rates, clean claim percentages, resubmission times, and the reasons for denials can help staff identify patterns. With these insights, they'll have complete visibility into any recurring problems clogging up their claims processes. 5. Outsource to a trusted vendor for extra support and expertise Finally, providers might consider outsourcing denial prevention to a specialist vendor who can help them develop the right strategy and toolkit to streamline billing, improve data integrity and manage claims to ease pressure on internal resources. Experian Health was client-rated #1 by Black Book™ ’24 in Denial & Claims Management Outsourcing, Health Systems. Learn more Proactively reducing claim denials These strategies raise an important question: can existing revenue cycle technology handle the increasing volume of denials? Healthcare administrators aren't convinced: only 54% of survey respondents feel their organization's technology is sufficient to meet demand, down 23 percentage points since 2022. To implement these denial prevention strategies effectively, providers may need to consider upgrading their toolkit rather than relying on traditional systems. Experian Health offers two AI-powered solutions that help providers better predict and prevent denials: Prevent denials with Patient Access Curator Too many denials originate in patient access, so prevention must start here. Patient Access Curator uses AI-driven data capture technology to verify patient details quickly and accurately. With a single click, PAC can automatically check eligibility verification, coordination of benefits, Medicare Beneficiary Identifiers, coverage discovery and financial status. Running multiple manual queries is a thing of the past, saving staff hours and propagating clean data throughout the entire revenue cycle. Watch the webinar to learn more about how Patient Access Curator helps prevent denials with accurate data from the start. Predict denials with AI AdvantageTM Clean data sets the stage for denial prevention, but AI adds an extra layer of protection by forecasting potential issues before it's too late. AI AdvantageTM does this in two ways. First, the Predictive Denials component analyzes claims using the provider's own ClaimSource® data and alerts staff to high-risk claims so errors, inconsistencies or missing documentation can be corrected before submission. Next, the Denial Triage component prevents missed revenue opportunities by segmenting denials and guiding staff to those worth reworking. See how AI Advantage works: If providers can't prevent denials, they can't protect their bottom line. With the right data analytics, automation and AI, providers can take control and spot issues before they become problems instead of spinning their wheels in endless rework. With more advanced tech on their side, it's possible to close the gap with payers and prevent denials, but it also gives staff the headspace to focus on patient care and support. Find out more about how Experian Health's Claims Management solutions help providers build effective denial prevention strategies and reduce lost revenue. Learn more Contact us
