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Claims denials are a thorn in the side of any healthcare organization. Even with claims denial mitigation tools and processes in place, denials are growing. In Experian Health's State of Claims 2022 report, 30 percent of respondents said denials increased between 10% –15% annually. To combat rising denials, ensure faster reimbursements, and improve the revenue cycle, healthcare providers need new claims technology that focuses on efficiency. In this post, learn about the common challenges in traditional claims processing and how to implement automated or AI-based claims management technology to drive healthcare revenue cycle efficiency. Challenges in traditional claims processing When it comes to reimbursement, the odds of being paid do not always favor the healthcare provider. The complexity of claims makes for labor-intensive workflows in traditional reimbursement processing. Data is often culled from multiple systems, including electronic health records (EHRs), paper files, diagnoses, test results, insurance verification, and more. Providers lacking a streamlined set of workflows supported by claims technology, experience errors that can lead to denied claims. Three of the most common challenges in traditional claims processing include missing or incomplete claims information, payer-related problems, and a need for more staff, which slows down processing productivity. 1. Missing or incomplete claim information Missing data is also a huge issue in traditional claims processing. In fact, missing or incomplete data is one of the top reasons for claims denials, particularly in the area of prior authorization. These mistakes often begin upstream at the first point of patient contact and, if not corrected, snowball toward the inevitable denial. Compounding the problem is that disparate healthcare systems and workflows make it increasingly challenging to collect all the data effectively. The larger the healthcare provider, the more touchpoints for claims processing, creating back-and-forth workflows that can lead to miscommunication or the loss of information. 2. Payer-related challenges Just keeping up with changes in payer requirements is a full-time job. Payers often change reimbursement requirements, and providers aren't aware of these new adjudication rules. It requires strict monitoring of all payers, which is impossible for organizations to manage. Prior authorizations are also increasingly burdensome for providers to handle. An AMA survey found that 88 percent of physicians said these burdens were high or extremely high. Providers estimated they process 45 prior authorizations weekly, equivalent to 14 hours of staff time. 3. Reduced or new staff can't keep pace Another challenge is not having the workforce necessary to review claims to identify errors. Workforce shortages continue to impact every healthcare area. The chronic challenge of high workloads and short staffing means most teams work as quickly as possible, leading to preventable mistakes. Without advanced claim technology, staff manually handle heavy workloads, which is driving denials through the roof. The lack of staff also affects traditional claims processing by slowing denials resubmissions. A less efficient denials management process directly affects provider cash flow, creating more delays in getting paid. Resolving these challenges requires modern, advanced claims technology powered by automation and artificial intelligence (AI). By leveraging this technology for claims management, healthcare providers can solve these problems for greater reimbursement efficiency and a better bottom line. Best practices for implementing AI-based claims management technology Experian Health data shows 51% of healthcare providers currently leverage some software automation. However, only 11% had integrated AI technology into their organization. Mounting evidence suggests preventing healthcare claims denials starts with innovative AI-driven claims management technology. AI and automation applied to a claim technology solution can prevent claims denials on the front-end of the patient encounter and improve denial management on the back-end of the process. When evaluating how to implement advanced claim technology, consider these best practices: Start by identifying the pain points in existing claims processing workflows. Review claims denials and mitigation data and talk with existing staff to develop this list. If the organization leverages legacy reimbursement tools, consider how efficiency gaps affect the organization. Consider organizational goals and objectives for replacing manual workflows or upgrading legacy claims management technology. As the organization explores the benefits of advanced claim technology featuring AI, develop use cases for employing these tools for more effective claims management. Compare new product features to these real-life scenarios. Seek stakeholder feedback. All technology rollouts require significant buy-in at every level in the organization. Don't miss engaging with the boots-on-the-ground workforce using the claims technology Ensure the organization has the infrastructure to support the new platform long after it goes live. When evaluating new digital tools, keep these things in mind: Select AI-based claims technology that utilizes workflow customization to manage the entire reimbursement cycle. Seek out a solution that automatically reviews each line in a claim to check for errors so that first submissions are accurate. Leverage a system with automation features that eliminate error-prone manual processes. Choose a platform that enables denial prediction and mitigation. Find a product with denials workflows and enhanced claims monitoring functionality. AI technology is the game-changer for healthcare's skyrocketing claim denial challenges. These new tools deliver immediate value to an increasingly disjointed and complex reimbursement process. With the right technology, healthcare providers improve the claims processing efficiency to get paid faster. Transformative impact of Experian Health's advanced claims technology Experian Health is a leader in digitally transforming traditional claims processing. AI-powered technology can increase staff efficiency at every stage of the claims management process. Experian Health's AI Advantage™, part of the Best in KLAS ClaimSource® platform, is transforming provider claims processing. This software reduces the need for additional staff by automating manual tasks. It lessens the burden on existing teams by lightening their claims processing and denials management workloads. AI Advantage has two primary solutions affecting every stage of the claims management process: Predictive Denials identify undocumented payer rules resulting in new denials. This AI-driven solution finds the claims most likely to fail, flagging them back to payment processing for correction before they're even submitted to the payer. Denial Triage manages prioritization of denied claims. Advanced algorithms in this solution identify and flag denials based on their potential value. Organizations maximize their returns on denied claims by focusing on the resubmissions with the highest financial impact. It removes the guesswork from reworking claims, lessening staff workloads by eliminating time wasted on low-value cases. Another solution, Patient Access Curator, uses AI and robotic process automation to enable healthcare staff to capture all patient data at registration, with a single click solution that returns multiple results – all in 30 seconds.  Experian Health's automated and AI-fueled advanced claim technology improves provider reimbursement efficiency at every stage of the process. The efficiency-related benefits of AI for claims management include avoiding denials, accelerating denial mitigation, and getting paid faster. To explore these tools—and their extraordinary ROI, contact the Experian Health team today.

“As the IU Health Revenue Cycle team rallied to respond to the claims processing disruption, we were uniquely positioned with our long-time Experian partnership to quickly re-institute critical claims routines and restore a significant volume of claims transmissions.  This would not have been possible without Experian's nimble and comprehensive approach, immediately applying talented and committed resources that leveraged existing Experian platform infrastructure.” – Bryan Daniels, Vice President Revenue Cycle Solutions, IU Health Challenge Indiana University Health (IU Health) is the largest network of physicians in Indiana comprised of over 38,000 team members and 2,717 available beds. Based in Indianapolis, Indiana, the organization has dozens of facilities statewide and is on a mission to make the state one of the healthiest in the nation. In February 2024, IU Health found itself impacted by the cybersecurity incident so many providers across the country abruptly faced. They were unable to send claims to insurance companies and their revenue cycle operations came to screeching halt. Knowing they needed a trusted solution fast, the revenue cycle leadership team asked Experian Health if they could help. Solution Conversations advanced quickly and the Experian Health team was able to implement its Best in KLAS ClaimSource® platform within a week. ClaimSource is an innovative claims management solution designed for scalability and improves revenue streams by minimizing denials. By using automation, it boosts operational efficiency by prioritizing claims, payments, and denials, allowing users to tackle high-impact accounts promptly. Outcome Thanks to ClaimSource, IU Health achieved the following results: Accelerated $632 million in claims transmissions in the first five days of business. Processed $1.1B of claims backlog by March 27.  “We value our longstanding partnership with IU Health and it's very rewarding that we were able to help in a very critical situation,” said Jason Considine, Experian Health's Chief Commercial Officer. “We know IU Health places the utmost importance on patient care, and being an important part of our client's solution to deliver on their service commitment is reflective of our service commitment to simplify healthcare.” Learn more about how ClaimSource can help your healthcare organization accelerate cash flow, reduce denials and optimize efficiency.

Healthcare leaders often zero in on how uninsured rates affect their bottom line. But another patient group presents a quieter financial dilemma for providers: those with multiple active health plans. In these cases, it's important to ensure each plan pays the right amount – in the right order. Should any confusion arise, providers may end up with their claims being denied, resulting in underpayments. This is where the coordination of benefits (COB) process comes in. What is coordination of benefits (COB) and why is it important? When a patient is covered by more than one plan, the “coordination of benefits” process kicks in to help health plans figure out their respective payment responsibilities. With patients often having multiple insurance policies, ensuring that each policy pays its share is vital. The purpose of coordination of benefits is to prevent overpayment or duplication of benefits, ensuring that the total benefits paid do not exceed the actual cost of the service received. Integrating a digital COB solution within registration and scheduling workflows can help providers ensure they bill primary and secondary payers correctly, preventing unnecessary claim denials. Challenges of coordination of benefits  Coordination of Benefits is a pivotal aspect of RCM, but it's not without its hurdles. Here's a look at the complexities that often arise:  Overlapping Policies: Determining which policy pays first can be confusing. Patients with dual coverage might not always be aware of the hierarchy, leading to billing complications. And many legacy systems only select the primary, without consideration for secondary or tertiary. And regional plans add another layer of complexity.  Claim Denials: Incorrect coordination of benefits can lead to claim denials or overpayments. This not only affects revenue but also strains the patient-provider relationship when patients are billed incorrectly.  Administrative Burden: Manual COB verification is time-consuming and prone to errors. Staff often spend hours cross-referencing policies, which could be better spent on patient care.  Coordination of benefits: the dream vs. reality In an ideal world, patients would register for care weeks ahead of their scheduled treatment. During the registration process, they would inform the provider of all their active insurance coverage, with correct and complete details close to hand. No plan would go unmentioned, and no policy number misplaced. Registration staff would quickly enter the information into their EMR without error, so coverage could be verified in real-time. The reality is far different. Recent findings show that 65% of consumers struggle to understand what their health insurance covers. They do not carry copies of their insurance cards. They may not be aware that they are covered under a relative's health plan. Patient access teams are under-staffed and over-stretched, with little time to ask guiding questions that would uncover additional insurance. Coordination of benefits efforts should start as soon as it becomes apparent that a patient has active coverage under multiple plans. Unfortunately, the messy reality of coverage discovery and patient registration means patients and providers are left in the dark until a claim is denied. The payer rejects the claim for a COB-related reason, leaving billers with no clue how to resolve it. The problem gets worse from there. Automating coordination of benefits for faster, cleaner claims As with all aspects of healthcare billing, there are many complex rules and regulations governing COB transactions. Under HIPAA, health plans and payers (including Medicare and Medicaid) must coordinate benefits for each patient and determine the primary and secondary payers. Tracking this manually is extremely challenging for providers: using the information provided by the patient (which may or may not be accurate), staff would contact each payer by phone or email to verify coverage. They would then review the COB rules and guidelines for each health plan to determine the primary payer and follow specific rules for billing secondary payers. It's no wonder that COB transactions are now among the most automated administrative tasks. Automating coordination of benefits not only saves staff time, but also increases the chances of finding all active coverage, collating complete insurance profiles for the patient, and making an accurate primacy determination. Digital systems also make it easier for providers and payers to communicate with one another, facilitating smoother dispute resolution and regulatory compliance. Patient Access Curator brings real-time COB to EH clients In late 2023, Experian Health acquired Wave HDC, bringing clients a new and unrivalled package of real-time coverage and benefits solutions based on AI-powered data curation. This new solution, Patient Access Curator, helps healthcare billing teams prevent claim denials in seconds through real-time data analysis. This includes COB curation, which automatically analyzes payer responses to identify hidden cues that staff cannot see. If other insurance is identified, the tool alerts the user and triggers additional queries to verify active coverage and build a complete insurance profile for the patient. Each policy is then analyzed further to determine the patient's primary, secondary and tertiary coverage, reliably sifting out any non-billable coverage. Since 2020, the technology powering Patient Access Curator has prevented denials amounting to more than $1 billion. Integrating coordination of benefits automation yields savings throughout the revenue cycle Integrating COB automation with other RCM tools, such as coverage discovery and eligibility verification, means providers can prevent and manage denials in a single workflow. Doing this during patient registration allows teams to resolve issues in the early stages of the revenue cycle, rather than wait to deal with them once claims are denied. While catching errors on the front-end results in faster patient registration and clean claims first time, the tool adds value later in the revenue cycle, too. Streamlining the correction process prevents revenue loss and reduces the need for manual intervention. Here's how these use cases look in practice: In one multistate practice, the technology automated COB curation with insurance verification during patient registration. This enabled primary coverage corrections for 12% of patient registrations and identified undocumented Medicare and Medicaid coverages for 6% of registrations. Left unchecked, these omissions would have resulted in denials, delays, and missed revenue opportunities. The technology was deployed in the denials workflow at a large health system, where it identified COB corrections for 92% of all COB denials. Of these, 60% were immediately refiled to the correct primary payer, minimizing delays in revenue recovery. In the remaining claims, the tool found evidence of inaccurate or outdated third-party liability records within payer claim adjudication systems. Providers urgently need revenue cycle processes to be as efficient and reliable as possible – especially when dealing with patients with multiple, complex health plans. A powerful denial prevention solution that slots neatly into the registration workflow means they can maximize revenue with minimal human intervention. And with accurate results delivered in seconds, Patient Access Curator could be just what the doctor ordered. Get in touch today to find out more about coordination of benefits automation and discuss other ways to increase efficiency on the front-end of the revenue cycle, using Patient Access Curator.