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Getting a claim right the first time is much less expensive than reworking it. Experian Health's 2022 State of Claims survey illustrates most claims denials result from simple human errors. Automation and claim scrubbing software help lower the burden of denied claims. But payer contract management software offers one of the most critical strategies for optimizing revenue cycle. These tools help providers maximize reimbursements throughout the lifecycle of their payer contracts.   Experian Health client OrthoTennessee, which has an 86% successful appeals rate, recovers hundreds of thousands of dollars annually by conducting contract audits and recovering underpayments with these tools. This result could extrapolate across healthcare if providers consider implementing payer contract management software.  Understanding the financial impact of denial rates Denial rates can significantly affect a healthcare provider's revenue. One study showed these administrative complexities cause $265 billion in healthcare misspending annually. Preventing claims denials should be a high-priority issue for healthcare providers. It's an untenable situation for cash-strapped healthcare providers, and by most accounts, the problem is getting worse.  Payer contract management software reduces denial rates. A well-managed contract ensures providers are reimbursed accurately and promptly, reducing denials due to billing errors or non-compliance. Individual payer contracts stipulate how and how much a healthcare provider gets paid. In addition to critical payment terms, payer contracts contain:  How many days a provider has to submit a claim  How many days the payer will take to reimburse a correctly submitted claim  The services and scope of coverage by payer  Reimbursement rates for every covered service  How to dispute a claim denial  The term of the payer contract  When to renegotiate or the notice period for a contract termination Most of these reimbursement contracts allow payer amendments. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, says, “Depending on how the contract is written, providers may receive very little notice of these changes. Without a way to systematically and efficiently monitor these agreements throughout the contract term, there is simply no way for a provider to ensure they're paid properly.” Better payer contract management can reduce denials and improve revenue collection by reducing the most common reasons for medical claim denials.  Proactive strategies for denial reduction Proactive denial reduction correlates with a better bottom line. This effort entails a multi-faceted approach with two key elements at its core: Analyzing payer contracts for pitfalls To mitigate denials effectively, healthcare providers must scrutinize payer contracts meticulously. By delving into the fine print, organizations can identify potential pitfalls and the sources of denials. Whether complex reimbursement terms, ambiguous language, or stringent coding requirements, a comprehensive contract analysis can unveil these challenges. Crafting contract strategies for denial mitigation With a deep understanding of contract nuances, providers can develop tailored strategies for denial mitigation. These strategies encompass streamlined claims submission and staff training. Additionally, organizations can engage in informed negotiations with payers to amend unfavorable reimbursement terms.  Through this fusion of contract analysis and proactive strategy development, providers can navigate the complex landscape of healthcare payer contracting with precision, ultimately reducing denials and bolstering financial stability.  Crafting comprehensive contract management strategies for denial mitigation Developing proactive strategies within payer contract management is a critical component of denial reduction.   For example, when creating payer contracts in healthcare, providers must proactively negotiate advantageous terms for their organization. These negotiations should focus on fair reimbursement rates, reasonable timeframes for claims submission, and other favorable conditions that minimize the potential for denials.  Strategies should also encompass addressing ambiguities in healthcare payer contracting. These misunderstandings lead to disputes and denials. Clarifying any vague or unclear language within the agreement ensures all parties have a shared understanding of the terms and expectations.  Finally, to mitigate denials effectively, healthcare payer contracts should align seamlessly with billing and coding practices. These contracts must reflect current industry standards and guidelines to prevent discrepancies resulting in claim rejections. Harnessing the power of payer contract management software in healthcare  Payer contract management software offers healthcare providers a powerful way to automate payer document analysis. A single provider can have 20 or more payer contracts to manage. From HMOs to PPOs, fee-for-service federal programs, third-party administrators, to ACOs and CINs—the payer list can be long. While a thorough analysis of healthcare payer contracting is essential to identify potential areas of improvement, it can be challenging to scrutinize all of these contract terms and conditions to mitigate future denial risks. But with the right software, this revenue cycle function can be a game-changer.  Payer contract management software can handle contract renewal and regulatory updates automatically, ensuring healthcare providers remain compliant. The software eliminates the hours spent manually reviewing data. Some of the benefits include:  Centralizing contracts in one location  Alerting significant milestones, such as contract renewals or changes  Automating processes and workflows  Linking contracts with provider procedures and complianc OrthoTennessee Manager of Payer Strategy, Frances Thomas, uses Experian Health's payer contract management software. She states, “The system gives us the information we need to be successful. They can't really argue with you on that.”  The role of automation in error reduction  Healthcare runs on revenue. Automation is pivotal for reducing healthcare claims errors that tie up revenue in the denials process. Automation software streamlines workflows, reducing manual intervention and the likelihood of human errors. These tools can apply across the revenue cycle, including during the payer contract management process. For example, Experian Health's payer contract management software includes Contract Manager and Contract Analysis features that can automatically:  Compare the expected payment with the actual reimbursement from payors  Maintain and manage contract terms  Pinpoint underpayments  Audit claims   Analyze claims data and the financial impact of potential changes to provider fee schedules  Highlight bulk claims for appeal en masse   OrthoTennessee highlights the importance of the ability to handle claims in bulk. Thomas says, “We had over 600 claims for one day in the wrong network. I was able to take that bulk of claims and handle those—otherwise, I was going to have to sit there and go claim by claim. It's a huge time saver to work smarter, not harder.”  Real-time verification and validation with automation Automated systems revolutionize healthcare operations by offering real-time verification and validation capabilities. Automation technology streamlines the billing process and minimizes errors that can lead to claim denials. It enhances efficiency and precision, allowing healthcare staff to allocate more time to patient care. As providers embrace automation, they can expect increased accuracy and financial stability. RevCycleIntelligence estimates the healthcare industry could save nearly 41%, or nearly $25 billion, of the $60 billion they spend annually by fully automating administrative transactions. But payers also stand to benefit; McKinsey says administrative automation could shave 30% off insurance claims processing costs.  Seamless integration of automation with payer contracts  Integrating automation tools with payer contracts in healthcare enhances efficiency. Integration ensures contract terms are consistently applied throughout the claims lifecycle, reducing denials. Interoperability between these platforms also improves the payer-provider relationship by increasing communication and streamlining processes.   Cross-platform integration creates two-way accountability that's a win/win for both provider and payer. It's a transformative step in healthcare revenue cycle management that could:  Streamline claims submission, verification, and adjudication  Continuously monitor claims for contract adherence and correct problems before they lead to denials  Reduce human errors  Apply advanced analytics to identify trends and patterns   Improve contract negotiations with data-driven decision-making  Lower administrative costs  Navigating challenges and embracing payer contract management software Healthcare providers face numerous challenges in revenue cycle management, especially when handling intricate payer contracts and the need for standardized handling of these documents. These challenges create scenarios where providers underbill or are underpaid for services, in addition to tying up revenue in denials management. Becker's Hospital Review reports providers lose up to 3% of their revenue from underpayments. Plus, the insurance industry isn't immune to making mistakes; the AMA says the claims processing error rate of public and private payers is more than 19%. By harnessing the power of technology, healthcare providers can streamline complex payer contracts and standardize how providers handle these agreements. For example:  To expedite negotiations, modeling tools within payer contract management software offer claim scenarios that help providers negotiate better rates from payers.  These systems provide real-time feedback through smart log messages, enhancing staff training and refining registration best practices.   Most healthcare organizations lack the time and resources to closely monitor payer contracts. When these agreements are on auto-renewal, it's easy to forget their importance. Payer contract management software helps these organizations wring the maximum amount out of these revenue streams. Embracing Experian Health's payer Contract Management software Experian Health's healthcare payer contract management software offers a comprehensive contract management solution that can substantially lower denial rates. By adopting this software, providers can maximize revenue potential and streamline their revenue cycle. Importantly, healthcare providers can implement payer contract management tools without adding staff or conducting major process improvements. This software is the one tool organizations need to ensure they don't leave revenue on the table. Learn more or contact us to speak to our experts.

Like many other sectors, healthcare providers are increasingly turning to automation and artificial intelligence (AI) to get more accurate data and better insights. However, the pace of change 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 in innovative ways. This is already evident in claims management, where executives are keeping an ear to the ground to learn of new use cases for AI to help maximize reimbursements. This article looks how AI and automation can help providers address the problem of growing denials, and how Experian Health's new solution, AI Advantage™, is helping one particular provider use AI to reduce claim denials. Using AI and automation to address the claims challenge 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. Changing payer policies and a changing payer mix layer on complexity. Labor shortages mean fewer hands on deck to deal with the workload, while rising costs and tighter margins mean the stakes are higher than ever. Manual claims management tools simply cannot keep up, resulting in lost time and revenue. 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 patterns in data, and synthesizing huge swathes of data to predict future outcomes. While AI is ideal for solving problems in a data-rich environment, automation can be used to complete rules-based, repetitive tasks with greater speed and reliability than a person might be able to achieve. Discovering new use cases for AI in claims management Providers are finding new applications for AI as utilization becomes more widespread. Some examples of different use cases include: Automating claims processing to alleviate staffing shortages: AI tools can use natural language processing (NLP) to extract data from medical records and verify accuracy before adding the information to claims forms. This saves staff significant amounts of time and effort. Augmenting staff capacity and creating an efficient working environment can also help with recruitment and retention. Reviewing documentation to reduce coding errors: AI can perform the role of a “virtual coder,” using robotic process automation and machine learning to sift through medical data and suggest the most appropriate codes before claims are submitted. Using predictive analytics to increase operational efficiency: One of the most effective ways to improve claims management is to review and learn from past performance. 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. Improving patient and payer communications with AI-driven bots: The claims process requires large amounts of data to be exchanged between providers, payers and patients. AI-driven bots can be used to take care of much of this, for example by automatically responding to payers' requests for information during medical necessity reviews, or handling basic inquiries from patients. Case study: How Community Medical Centers uses AI Advantage to predict and prevent claims 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 that are 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 turnovers. AI Advantage eases the pressure by automatically detecting changes in the way 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 any 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.” Hear Eric Eckhart of Community Medical Centers and Skylar Earley of Schneck Medical Center discuss how AI Advantage improved their claims management workflows. AI AdvantageTM: two steps to reducing claim denials AI Advantage works in two stages. Part 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, this helps providers prevent denials before they occur. Part 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 make the biggest impact to their bottom line. At CMC, denials teams had previously focused on high value claims first, but found that smaller payers sometimes made erroneous denials that could add up over time. AI Advantage helped root these out so Eckhart's team could resolve the issue with payers. Integrated workflows reveal new applications for AI and automation AI Advantage works within ClaimSource®, which means staff can view data from multiple claims management tools in one place. In this way, AI Advantage fits into the same workflow as tools that providers may already be using, such as Claim Scrubber, Enhanced Claim Status and Denials Workflow Manager. These integrations amplify the benefits of each individual tool, giving healthcare providers better insights into their claims and denials data. With richer data, organizations will find new ways to leverage AI to increase efficiency, reduce costs and boost revenue. Discover how AI Advantage, Experian Health's new claims management solution, can help providers use AI to reduce claim denials.

As 2023 draws to a close, revenue cycle leaders are in planning mode, reviewing financial performance, and gearing up for resource allocation negotiations in the new year. What should they be prioritizing? Three of Experian Health's senior executives share their healthcare predictions for 2024 based on the latest healthcare trends, and the steps providers can take to maximize reimbursements in the year ahead. Healthcare prediction #1: “Staffing shortages will persist, driving demand for technology-based solutions over traditional HR tactics” According to Jason Considine, Chief Commercial Officer, the healthcare staffing shortage is unlikely to let up any time soon: “In our recent survey, we found that 100% of respondents are seeing ongoing shortages affect revenue cycle management and patient engagement. There's an urgent need to address the problem, but too many providers are relying on traditional recruitment approaches that won't give them the longer-term resilience they need. Heading into 2024, providers should leverage technology and data to alleviate the burdens on front and back-end operations, and drastically improve efficiencies. This will better protect providers from the talent pipeline fluctuations that cause major disruptions.” This healthcare prediction for 2024 is based on Experian Health's staffing survey that was relased in 2023. Participants in the survey agreed that the staffing crisis would continue, expressing concerns about its impact on revenue and patient engagement. For many, the culprit is high turnover rates. More than four in ten said turnover in their administrative teams exceeds 25%. Given the difficulties in finding skilled candidates and addressing staff burnout, it seems clear that traditional HR-based strategies will fall short. Despite this, salary increases, cross-training and incentives remain go-to responses. Responding to the survey findings, Considine says, “It's time to look at the many areas where automation – and even artificial intelligence – can stabilize, improve and optimize understaffed functions.” One use case for artificial intelligence is in claims management. Experian Health's AI Advantage™ solution uses historical and real-time claims data to identify claims that may be at risk of being denied. This allows staff to zero in on those claims and ensure all information is correct and complete before submission. It integrates seamlessly with ClaimSource® to augment the claims workflow, so staff can focus on claims and denials with the highest likelihood of payment. As well as alleviating pressure on staff, it reduces costs and maximizes reimbursements, helping providers to protect margins during uncertain times. See how AI Advantage helps healthcare organizations reduce and prevent claims denials. Prediction 2: “Patients' changing digital expectations will prompt more providers to adapt (and those that don't will risk losing market share)” Clarissa Riggins, Chief Product Officer, says that patients are increasingly likely to expect a better “digital front door” experience, and will start to look elsewhere care if they encounter too much friction: “Patients have increasingly high expectations for easy and efficient tech-enabled solutions when it comes to accessing healthcare services. They seek convenient self-scheduling options, accurate cost estimates, and the ability to pre-register through their smartphones. We're seeing a continuing trend in the number of patients who say they'd switch providers if the digital front door isn't open.” That healthcare trend was evident in Experian Health's State of Patient Access 2023 survey, which showed that 56% of patients who had seen a deterioration in the patient access experience would switch providers because of it. Demand for more digital options can be tracked back to the “Amazon effect” and the rise of online retail environments that give consumers convenience and choice at the tap of a button. Indeed, healthcare providers stepped up during the pandemic to deliver flexible, contactless care, so patients have seen that it's possible. With digital transactions now well-established, patients will find it surprising to be asked to fill out paper forms at the registration desk or have limited online payment options in 2024. Riggins says providers must update their technology or risk being left behind. “Clients who are making the switch to digital patient access offerings tell us they don't want to look stuck in the 90s. They want a more contemporary patient experience that's smoother and more efficient for both patients and staff.” To open the digital front door and kepe up with healthcare predictions in 2024, Riggins recommends prioritizing self-service and digital options for patient registration, scheduling and billing inquiries. Prediction #3: “More patients are struggling financially, so providers will need to do more – and sooner – to help them manage bills” Victoria Dames, Vice President of Product Management, says that with household finances under pressure, patients will remain anxious about the cost of care: “The earlier providers can give patients clarity, the better for all involved. Creating a convenient and transparent patient collections experience should begin during patient onboarding, so patients can start to plan. With integrated patient access software, providers can deliver a more compassionate and efficient collections process, which supports patients while accelerating the revenue cycle. They don't have to choose between prioritizing revenue and patient experience – patient access technology delivers on both.” Recent Experian data suggests that many Americans are not confident in their financial literacy. This does not bode well for their ability to navigate the increasingly complex processes involved in healthcare billing. The troubling health consequences are already evident: a 2023 Gallup poll revealed that record numbers of patients were putting off medical care because they were worried about the cost. Anything providers can do to simplify the payment process is going to improve access to care and minimize bad debt, as noted in Dames' healthcare predictions for 2024. Dames says the collections effort should be viewed as an ongoing interaction with patients, beginning in patient access: “Patient access is where providers begin collecting data, confirming insurance eligibility, and providing accurate patient estimates. Completing these actions successfully at the beginning of the patient journey, with compassionate and frictionless patient interactions, can facilitate payment and collections downstream.” A better financial experience in 2024 should include self-service and digital tools that guide patients through each step of their financial journey. For example, PatientSimple® gives patients a user-friendly, comprehensive way to generate price estimates, apply for charity care, set up payments plans and even make payments, all through a single web-based portal. Patient Payment Estimates deliver accurate pre-service cost estimates through the patient's preferred channels and point them toward any appropriate financial assistance. And of course, offering a wide range of convenient and flexible payment options will promote timely payments and maximize collections. Learn more about our revenue cycle management solutions or contact Experian Health today to discuss how we can support your strategies, based on our healthcare predictions for 2024.