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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

Today's patients are used to the seamless and transparent payment processes in retail services. It's no surprise that they expect the same convenience with paying for healthcare. According to Experian Health's State of Patient Access 2024 report, 96% emphasized that it is crucial they receive an accurate estimate of treatment costs before service. In fact, 43% said they would opt out of receiving care if this information were unavailable. Patients also expect more payment options, including online and mobile payments, as confirmed by 72% of respondents. However, the reality is far from ideal for most patients. From unexpected medical bills to convoluted payment processes, the patient payment journey is anything but straightforward, and hospitals feel the consequences the most in their bottom lines. Unclear and confusing payment processes can lead to healthcare collection issues, impacting hospital financial stability. Discover how Experian Health's Collections Optimization Manager solution makes patient billing and healthcare collections more transparent, responsive and streamlined. Why Collections Optimization matters for mid-size healthcare providers Collections optimization involves leveraging technology to simplify and accelerate the process of collecting payments from patients. These solutions screen, segment and monitor accounts for efficient payment collections. Healthcare collections for mid-size providers is essential as they need a consistent cash inflow to stay afloat. With healthcare costs rising, affordability is a growing concern for patients and providers. About half of US adults find it challenging to cover their healthcare costs; one in four report needing help paying for healthcare within the last year, as per a KFF survey. In addition, according to Experian Health's State of Claims 2024 survey, 77% of providers are moderate to extremely worried about patient payments. By improving collections optimization, mid-size providers can assess patients' financial responsibility and capability as early as during patient registration. This allows them to prioritize high-value accounts and write off or refer other cases to collection agencies. Experian Health vs. Competitors: The key differentiators in healthcare collections for the mid-sized market Experian Health's Collections Optimization Manager solution outperforms the competition, by ensuring healthcare organizations receive personalized, automated and thorough support to manage healthcare collections. Automation: reducing costs and improving efficiency When it comes to healthcare collections for mid-size providers, many still rely on manual processes that exhaust limited staff resources and delay payment collections. Collections Optimization Manager provides end-to-end automation capabilities that streamline the entire healthcare collections process from patient registration to final payment. It automates critical components of healthcare collections, including payment capability screening, segmentation and payment monitoring, based on each organization's challenges and revenue cycle process. This automated collection approach conserves hospital resources and ensures payments move faster into their pockets. For instance, Wooster Community Hospital (WCH)  observed patient payments increase by $3.8 million a year after adopting Experian Health's Collections Optimization Manager, alongside PatientDial and PatientText. In a recent webinar, Kristen Shoup, Revenue Cycle Director at Wooster Community Hospital, and Judy Wirtz, Senior Analytics Consultant at Experian Health, discuss, “By automating Wooster's collection calls, we've been able to maximize in-house collections and boost their recovery rates.” Segmentation: optimizing receivables with data-driven insights Ensuring that care delivered is met with prompt payments is a top priority for healthcare organizations. With its advanced capabilities, Collections Optimization Manager provides a solution. One standout feature is its segmentation tool, which utilizes data-driven insights, including credit, behavior and demographic data, to categorize accounts based on their financial capabilities and situation. This approach helps organizations determine which patients most need payment arrangements and have self-sufficient accounts. Healthcare organizations can then optimize self-pay collections by prioritizing and targeting accounts with high propensity-to-pay scores. Segmentation also empowers healthcare organizations to make appropriate decisions on patient accounts with a low propensity to pay. This approach is one of the ways Wooster made the most of Collections Optimization Manager. “We have used the data with the propensity-to-pay scoring to help develop presumptive charity program within our organization and write those accounts off that have a low propensity-to-pay score,” Shoup elaborates. Dedicated collections consulting: personalized support for success Experian Health's Collections Optimization Manager comes with the extra support of dedicated revenue cycle consultants and data analysts, who can provide personalized guidance and customized workflows. These consultants work closely with hospital revenue cycle teams to offer customized strategy support, industry know-how and best practices to improve collection efforts. Wirtz explains Experian Health's partnership with Wooster's team: “We (the team and consultants) meet every other week and talk about performance, any new initiatives and any pain points that Wooster might have.” IVR and texting solutions: enhancing patient communication Another competitive advantage of utilizing Collections Optimization Manager for healthcare collections is enhanced patient communications, through PatientDial and PatientText. These products offer dialing and text messaging patient outreach services to improve collections, payments and patient engagement. With PatientDial and PatientText, providers can utilize an interactive voice response (IVR) that processes automated payments made over the phone and redirects calls to the appropriate agents, depending on the nature of the inquiry. What's more, teams are already seeing success with this integrated approach. Wirtz explains, “Since adopting PatientText, Wooster has seen a significant improvement in the patient collection complaints and has made the payment process much more convenient and less disrupted for their patients. [Experian Health] made things easier for the Wooster team by adding IVR, which reduces the need for agent interaction. So now patients can handle payments and manage their accounts on their own over the phone.” Cost savings: maximizing ROI for mid-sized providers The most evident competitive advantage of adopting Collections Optimization Manager is maximized return on investment (ROI) for mid-sized providers.  Revenue cycle teams can tailor their approach to each patient segment by segmenting accounts based on their likelihood to pay. This allows them to develop efficient strategies for healthcare collections and collect a higher percentage of outstanding payments more efficiently, with minimal delays and effort. The results for mid-sized providers: Clients have achieved an ROI of 9:1. How Experian Health's healthcare collections solutions drive results for mid-size providers The stakes are high when it comes to medical collections for mid-size providers: every passing minute of inaction means money slipping through the fingers of hospitals. Collections Optimization Manager is an industry-leading data-driven solution that enables revenue cycle management staff to accurately determine patient financial situation and responsibility from account creation and collect self-pay receivables through the most appropriate and effective measures. The benefits are indisputable: Sanford Health, the nation's largest non-profit, rural healthcare system, saw the most benefits with the segmentation feature. The healthcare system wanted a patient-focused, hybrid solution and found Experian Health's Collection Optimization Manager to be the perfect fit. Since the organization first implemented Collections Optimization Manager in October 2014, it has gained a total in-house patient collection lift of $40+ million, with an average monthly increase of $2.3 million. Why Experian Health is the best choice for mid-sized healthcare providers In an era of increasing healthcare consumerism, rising operational costs and high-deductible plans, hospitals looking to maintain steady cash inflow must rethink their payment collection approach. This need is especially pronounced for hospitals relying on manual processes, a reality for many mid-sized healthcare providers. Collections Optimization Manager delivers optimal automation and efficiency in how hospitals and health systems approach patient financials and collect payments. It is also well-suited for both in-house and agency collections teams. Contact us today to learn more about how Experian Health can help improve healthcare collections for mid-size providers and improve bottom lines with our Collections Suite of solutions. Learn more Contact us

Flu season is rapidly approaching, which means healthcare providers must ramp up their preparedness efforts. What can they do to ensure they're ready to meet the seasonal surge in demand? Recent data from the southern hemisphere, often a forecast of what's to come in the US, suggests that this year's flu season will likely be similar to last year. The CDC warns that while “we cannot predict what will happen in the United States this upcoming season, we know that flu has the potential to cause significant illness, hospitalizations and deaths.” With hundreds of thousands of people hospitalized each year, providers must find ways to prepare for rising patient volumes and manage the risk of infection among patients and staff to keep services running smoothly. Making it as easy as possible for patients to book and attend vaccination appointments will be critical. Digital patient access will be the key to streamlining patient care. Using digital tools to prepare for flu season 2024-25 As services face increasing pressure, digital and automated tools can help healthcare providers prepare for flu season by easing staff burdens. More patients mean more appointments to schedule, more registration forms to fill out and more people in waiting rooms. Opening the digital front door helps manage high volumes by allowing patients to complete more access tasks online and prevent bottlenecks. Here are three strategies to implement to support staff and patients through a challenging season: 1. Manage infection risk with online self-scheduling An online patient scheduling platform has two clear benefits – it relieves pressure on staff during busy times and gives providers control over patient flow. Fewer calls need to be made by call center agents. No-shows are less likely because patients can book, reschedule and cancel appointments, and receive automated reminders, which makes the best use of physicians' time. Online scheduling also plays a part in infection control as providers can incorporate screening protocols to identify patients with symptoms of COVID-19 or flu, and manage their onward care pathway appropriately. Empowering consumers to take control of their healthcare with a patient scheduling system might encourage vaccine registrations, which could help reduce the burden on health services when staffing shortages remain stubbornly high. What's more, patients now expect the flexibility and convenience of scheduling appointments at a time and place that suits them. Experian Health's 2024 State of Patient Access survey found that six in ten patients want more digital tools to manage their healthcare. This indicates a growing demand for easy, simple and transparent processes. Watch the webinar: See how IU Health used self-scheduling to manage increasing patient volumes with less staff – and gain insights on using digital scheduling to scale operations beyond flu season. 2. Offer mobile registration to manage demand Should patient volumes increase, patient access staff will be under even more pressure than usual. Anything that can reduce the administrative burden will be a win. Experian Health's Registration Accelerator allows patients to complete intake forms and insurance checks through their mobile devices before stepping through the door. Their details can be pre-filled automatically, reducing the risk of error. This creates a quicker, more efficient patient registration experience that minimizes issues for staff to resolve. Mobile-enabled registration is also far more appealing for patients, who'd rather complete registration from the comfort of home than sit in a waiting room filling out lengthy forms. Plus, it reduces in-person interactions, thus minimizing exposure to infection among staff and patients. Given that 89% of patients say digital or paperless pre-registration is important to them, providers that offer online patient intake solutions will have a clear advantage in attracting potential new customers during times of high demand. In practice: See how West Tennessee Healthcare replaced clipboards with clicks with Registration Accelerator. 3. Reduce no-shows and increase engagement with automated patient outreach Providers must communicate proactively with patients to keep them in the loop as the situation evolves. With an open rate of 98%, text messages are a direct and convenient way to communicate quickly with patients. Automated patient outreach can increase vaccination rates by notifying patients about flu shot availability and offering a direct link to schedule an appointment. Automated reminders reduce no-show rates and help ensure no slot goes unused as patient volumes increase. Messages can also include tailored instructions for specific at-risk groups to emphasize the importance of timely vaccination and provide directions. This approach helps manage patient flow, increase patient satisfaction and ensure providers are prepared for the seasonal surge. Contact Experian Health today to learn how digital patient access solutions can help healthcare providers prepare for flu season in 2024. Learn more Contact us