Tag: contract management

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

Effective contract management for healthcare organizations is pivotal in this complex and highly regulated world. Healthcare organizations, whether large hospitals, clinics, or individual practitioners, contract with various entities, including vendors, insurance providers, and regulatory bodies. These contracts govern everything from purchasing medical supplies to services reimbursement, making healthcare contract management a critical aspect of running a successful and compliant operation. What is healthcare contract management? Healthcare contract management is the systematic process of creating, negotiating, executing, monitoring, and optimizing contracts to ensure compliance, mitigate risks, and achieve healthcare organizations' strategic objectives. It encompasses various stages, including needs assessment, drafting, execution, and post-contract management. The importance of healthcare contract management for payers and providers Healthcare contract management ensures that healthcare organizations, including payers and providers, can efficiently navigate the contracts governing operations. For providers and healthcare contract managers, it's about ensuring their organization gets paid fairly for services while adhering to complex regulations. For payers, negotiating contracts with healthcare providers helps control costs while maintaining care quality. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, states, “Better healthcare contract management directly impacts provider revenues. That's why many organizations implement healthcare contract management software. These tools help healthcare providers work smarter and get paid faster.” Challenges and opportunities in healthcare contract management The complex payer/provider landscape presents multifaceted challenges for organizations seeking to improve healthcare contract lifecycle management. The intricate web of regulatory requirements, privacy laws, provider-specific reimbursement structures, and shifting payment models adds complexity to contract management. Healthcare providers must navigate through contracts with various stakeholders, including suppliers, payers, and government agencies. Healthcare contract compliance with ever-evolving regulations is difficult in part because most providers manage these complexities manually. Providers seeking to improve healthcare contract management often turn to technology to help. OrthoTennessee, a multi-location orthopedic practice in Knoxville, Tennessee, with 164 providers, struggled with denied claims, smaller payouts, and a need for more contract management standardization. The organization used Experian Health's Contract Management tool to improve the accuracy of contract compliance. Today, this healthcare provider credits the software with helping the organization spot changes in payer rules and trends in how they pay. Experian Health's Contract Management platform drives significant efficiencies and time savings. It also provides critical data for payer negotiations. In 2022, OrthoTennessee had an 86% appeal success rate, thanks to more streamlined contract management. OrthoTennessee strongly advocates for Experian Health's Contract Management tool—and they've used it for over 16 years. Navigating the complex landscape of healthcare contract management The healthcare industry is notorious for its ever-evolving regulatory environment. Healthcare contract managers must stay up-to-date with these changes to ensure contracts remain compliant. Imagine doing this by hand when most healthcare providers deal with hundreds of different payers, each with its contracts, procedures, and paperwork. This lack of standardization slows down the claims process. With rising healthcare costs, payers and providers are under immense pressure to optimize contracts to maintain profitability while delivering quality care. As claims grow more complex and patient volumes rise, manual healthcare contract management becomes a bottleneck in getting paid. Healthcare organizations often operate in a highly competitive environment, making efficient contract management a strategic imperative. Failure to manage contracts effectively can result in lost revenue, operational inefficiencies, and strained relationships with key partners. Managing data-intensive healthcare contracts One of the most significant challenges in healthcare contract management is the data-intensive nature of these agreements. Payer/provider contracts contain vast amounts of critical information, such as billing codes and reimbursement rates. Managing this data accurately and securely is essential for compliance and successful operations. The sheer volume of contracts in healthcare organizations can be overwhelming, making it challenging to track, analyze, and report on their performance. Manual contract management processes are vulnerable to errors that can have significant financial and legal consequences. However, these challenges also present significant opportunities. The advent of technology, such as contract management software and artificial intelligence, has revolutionized the way healthcare organizations oversee contracts. These tools offer the potential to automate data extraction, analyze compliance, and streamline contract workflows, significantly enhancing efficiency and reducing the risk of errors. Frequently Asked Questions What does a healthcare contract manager do? A contract manager in healthcare is responsible for overseeing the entire contract lifecycle. Their duties include negotiating contract terms, ensuring legal compliance, monitoring performance, managing amendments and renewals, and fostering stakeholder collaboration. Contract managers play a vital role in optimizing contract efficiency and minimizing risks. What are the common types of contracts in healthcare? Provider Agreements: Contracts between healthcare providers (e.g., hospitals, clinics) and payers (e.g., insurance companies) that outline reimbursement rates and service delivery terms. Payer Contracts: Agreements between healthcare payers and providers that govern payment terms, coverage, and network participation. Pharmaceutical Agreements: Contracts between healthcare organizations and pharmaceutical companies for purchasing and distributing medications. Vendor Agreements: Contracts with vendors providing services, equipment, or supplies to healthcare organizations, ensuring quality and compliance. Better healthcare contract lifecycle management Healthcare contract lifecycle management is a comprehensive process encompassing all contract stages, from initial creation to final execution, performance monitoring, and eventual termination. This systematic approach helps organizations maximize efficiency, reduce risks, and ensure compliance with payer contract requirements. Understanding the contract lifecycle The lifecycle of an average contract has several phases. Work must be done at each step, and challenges arise even before contract signing. After signing, the healthcare contract manager must follow each payer's rules closely as they are subject to change. Pre-Contract Stage: Healthcare organizations must conduct a thorough needs assessment to define the agreement's scope before drafting a contract. This phase often involves communication with essential finance, legal, and operations stakeholders. The goal is to go into contract negotiation with a clear sense of organizational goals and where to draw the line. Payer Contract Formation: Successful contract formation involves negotiation and drafting that addresses all parties' unique needs and expectations. Key stakeholders must collaborate to ensure the contract meets legal and regulatory requirements. Standardized templates with clear, concise language minimize ambiguity and lessen legal risks. Execution of Contracts: To expedite contract execution, healthcare providers must establish approval workflows and methods for monitoring compliance after signing. This phase may include exchanging required documentation, such as insurance certificates or provider credentials. Notably, adopting e-signatures streamlines approvals, reducing common delays experienced with paper-based processes. Post-Contract Management Performance: After execution, healthcare organizations must actively and consistently monitor contract metrics against key performance indicators (KPIs). Providers must identify deviations from expected performance and address them quickly. Keep in mind healthcare contracts often require amendments and periodic renewals. Organizations must also have a standardized process for these changes and ways to manage new contract compliance workflows. How technology improves the contract lifecycle Technology plays a pivotal role in improving the entire healthcare contract lifecycle. From contract creation to execution, performance monitoring, and beyond, technology-driven solutions offer a range of benefits to enhance efficiency and improve compliance. Contract management software has revolutionized how organizations handle their contracts in the digital age. These specialized platforms offer a centralized repository for contracts, making them easily accessible and searchable. Critical features of contract management software include: Centralized Storage: Consolidates all contracts into a single, easily accessible database, eliminating the need for physical filing systems or scattered electronic documents. Automated Workflows: Reduces delays associated with manual routing and approvals. Electronic signatures further expedite contract execution. Version Control: Maintains a clear record of revisions, ensuring users consistently access the latest, up-to-date documents. Document Management: Aids collaboration, secure file storage, and document sharing. Alerts and Reminders: For contract milestones, such as changes, renewals, or termination dates, helping organizations stay on top of critical events. AI and automation in healthcare contract management AI can automatically extract essential contact data, helping organizations efficiently categorize, analyze, and report on their contract portfolio. Natural language processing and machine learning aid in contract risk assessment, compliance checks, and pinpointing critical clauses for review. Automation tools can generate contracts from standardized templates, reducing the time and effort required for contract authoring and negotiation. AI-driven contract review tools help legal and compliance teams identify deviations from standard language, flagging potential issues that need attention. Compliance checks and alerts can also be automated, ensuring that contracts meet changing regulatory requirements. Data analytics for contract oversight Data analytics for contract oversight is invaluable for overseeing contract performance and compliance. By employing data-driven insights, organizations can: Monitor KPIs to assess whether a contract is delivering the expected value. Detect anomalies, deviations from expected patterns, or changes in performance data to identify potential risks and compliance issues. Manage costs by analyzing financial data within contracts and identifying opportunities for cost reduction or resource optimization. Predict contract performance trends, helping organizations proactively address issues and make informed decisions. Ibrahim says, “There's a reason that Experian Health Contract Manager achieved Best in KLAS this year. The burden of proving a claim is underpaid or wrongly denied always rests with the provider. This software finally allows these organizations an opportunity to reduce the $157 billion annually lost on manual contract management.” Future of managing healthcare contracts The future of managing healthcare contracts will be transformational. Technology advancements will revolutionize the standard for healthcare contract lifecycle management. As technology advances, organizations that leverage these innovations stand to gain a significant competitive advantage in their revenue cycle. Some of the future innovations to expect include: Telehealth and Remote Contract Management: Telehealth will become integral to healthcare delivery. It will extend beyond traditional video consultations to include remote monitoring, diagnostics, and treatment plans and require a robust framework for contractual agreements between healthcare providers, insurers, and technology vendors. The expanding role of telehealth will necessitate innovative contract management solutions, leveraging technology and automation to ensure efficient, secure, and compliant remote contract management. Predictive Analytics and Machine Learning: These emerging technologies will reshape how healthcare providers manage contracts. Predictive analytics will enable organizations to anticipate contract performance trends, proactively identifying potential issues before they escalate. Machine learning algorithms can analyze vast amounts of contract data to uncover patterns and insights that may not be apparent through traditional methods. This predictive capability helps healthcare organizations optimize their contract management strategies, improve negotiation outcomes, and enhance overall operational efficiency. By leveraging these advanced technologies, healthcare providers can ensure compliance, reduce risks, and drive better financial and patient care outcomes. Empowering healthcare organizations for a successful future Ultimately, applying technology solutions to healthcare contract compliance and management empowers these organizations to succeed in delivering high-quality care. Healthcare is increasingly complex, and organizations must leverage technology, adopt best practices, and stay ahead of emerging trends. Experian Health's Contract Management solution allows providers to manage these complexities efficiently and improve their revenue cycle. Contact us to learn how our Healthcare Contract Management software can help your organization validate reimbursement accuracy, recover underpayments and more.

Many healthcare providers believe pairing “revenue cycle” with a qualifier like “predictable” is an oxymoron. From healthcare staffing shortages that slow down reimbursement tasks to increasing payer denials, financial regularity can seem like an unattainable goal for these organizations.  The American Hospital Association (AHA) reports over one-half of U.S. hospitals had financial losses in 2022. Another AHA survey shows that 84% of these organizations say the cost of complying with complicated payer policies is climbing. Providers throw an excessive amount of time and staff at chasing revenue, but reimbursement complexities make for anything but smooth financial sailing. How can healthcare providers even out the ebbs and flows of the revenue cycle? Experian Health's suite of revenue cycle management (RCM) solutions can help. Revenue cycle predictability during the life of a claim When it comes to finances, U.S. healthcare providers rarely have an easy go of it. Today, the average life of a claim is anything but average. From registration to collections, hospitals established a new normal over the past decade: Widening gaps between service delivery and reimbursement. How can providers tackle this untenable situation? The answer is two-fold: with technology and at each stage of the life of a claim. Here are three ways healthcare providers can use technology to create reimbursement predictability at each stage of a claim's life. 1. Establish payment accountability at patient registration with price transparency Reimbursement problems begin at patient registration. Healthcare price transparency demands patients understand the cost of care. According to Experian Health's State of Patient Access survey, 81% of patients agreed that an accurate estimate helps them better prepare to pay for their care costs. However, only 31% of patients received a cost estimate before care. There are three significant impacts of this troubling trend: Nearly 40% of patients say they put off needed care due to cost. The number rises to 61% if the patient is uninsured. Patients can't afford to pay for needed care. Currently, 41% of U.S. adults have medical debt. An Experian Health study showed four in 10 patients spend more than they can afford on healthcare treatment. Uncompensated care causes a significant drop in healthcare provider income, which has amounted to almost $745 billion, according to the AHA. Experian Health offers several data-driven solutions to improve price transparency. These tools make it easier for patients to handle their financial responsibilities while helping providers find solutions to help ease their burdens.Patient Financial Advisor creates more accurate service estimates for patients before their procedure. The mobile-first platform offers patients a detailed cost breakdown on their preferred digital device. Patient Estimates is a web-based platform offering real-time service estimates. Blessing Health System uses the tool to provide patient estimates that are up to 90% accurate. The provider increased collections by 58% and credits the software with a 1,200% return on their investment. Patient Access Curator automatically initiates communication with payers to improve coordination of benefits and maximize return. It also automatically identifies missing or incorrect Medicare Beneficiary Identifier (MBI) numbers or errors in patient contact details. This solution also helps providers understand the patient's ability and propensity to pay, allowing these organizations to predict revenue streams after service delivery. Behind the scenes, Experian Health also automates insurance eligibility verification to unlock hidden reimbursements. This software roadmaps the correct coverage, connects to more than 900 payers and verifies insurance coverage at the time of service to improve cash flow and ease patient payment burdens. 2. Reduce claim denials by decreasing manual paperwork errors Claim denials are one of the biggest impediments to revenue cycle predictability. Providers are stuck in an endless cycle of inaccurate payer submissions, rejected claims, and rebilling, creating a chaotic chase for payment long after the service. Today, 35% of healthcare organizations report $50 million or higher in lost revenue due to claims denials. Even worse, Experian Health's State of Claims 2022 report showed that 30% of providers say denials are increasing by up to 15%. According to that data, the top three reasons for claim denials are: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Coding inaccuracies. Experian Health's Claim Scrubber software levels out provider cash flow, creating predictability amidst the chaos. The solution reviews complete claims for errors, generating actionable edits before submission. Claim Scrubber also reviews approved reimbursement rates to prevent undercharging. Transactions process within three seconds and providers reduce the need to rework claims. Experian Health's AI Advantage solution uses the power of artificial intelligence (AI) to evaluate every claim for its propensity to turn into a denial. Instead of submitting claims and hoping the payer will accept them, this solution takes the guesswork out of reimbursement for a more rational, predictable process. The software automatically scans for payer updates to reimbursement requirements that significantly contribute to claims denials. Hospitals like Schneck Medical Center use this tool to streamline the revenue cycle by preventing denials. After just six months, the provider’s denied claims reduced by an average of 4.6% each month. Claim corrections that took up to 15 minutes manually are now processed in less than five. 3. Increase collections efficiency with automation Patients trust their healthcare providers to take care of them. Providers also rely on patients to pay their bills. It's a mutually beneficial arrangement. However, it's also a problem forcing providers to walk a delicate tightrope between caring for a sick patient while still chasing payment for their services. Unfortunately, the increasing cost of healthcare leaves patients on the hook for more than $88 billion in debt. The volume of healthcare payments in arrears is staggering, causing a substantial drain on provider cash on hand. However, technology offers healthcare providers a way to improve the patient collections process. For example, Coverage Discovery impacts the revenue cycle at every stage of the claim: Before providing care, the software scans patient data to determine reimbursement coverage options from Medicaid, Medicare, and commercial insurance. It scans for active insurance 30, 60, and 90 days after care delivery. The tool scans patient data before determining whether the account moves to bad debt collections. A more robust understanding of patient payment options at every stage of claims management allows healthcare providers to forecast reimbursements more accurately, increasing the predictability of the revenue cycle. Collections Optimization Manager provides organizations with actionable insights, so that providers can segment and prioritize accounts by proprensity to pay. This solution increases patient collections by leveraging Experian's data driven segmentation models, and helps providers screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Experian Health's AI Advantage – Denial Triage prioritizes rejected claims based on their yield potential, automating workflows for claims managers so they focus first on the patients more likely to pay. This tool segments denials based on their potential value to help even out the revenue cycle with a faster rate of financial return. Denial Triage expedites A/R by increasing revenue collection per person per hour. Revenue cycles can be more predictable, but the complexities of reimbursement require technology to achieve this goal. Experian Health offers a comprehensive line of revenue cycle management solutions to help healthcare providers maximize collections and improve RCM. Find out why Experian Health ranks Best in KLAS for 2024 in the categories of Claims Management & Clearinghouse and Revenue Cycle: Contract Management, or contact us for a more predictable revenue cycle, better cash flow, and a healthier organization.

Contracts govern the revenue cycle, but negotiating contracts and ensuring compliance can feel increasingly unmanageable as mergers and acquisitions, ongoing staffing challenges, and the sheer volume of contracts, plans, and provisions make contract management a massive project for healthcare providers. Tricia Ibrahim, Director of Product Management at Experian Health, shares her insights on a challenging environment heading into 2024. Providers are grappling with mounting complexity, an explosion of data, and continuing pressure to maximize efficiency and revenue. But, according to Ibrahim, healthcare contract management software is evolving to meet these challenges—and helping providers find clarity amid the complication. Q1: What are the major challenges with healthcare contract management as we move into 2024? “I think what clients are most concerned with, especially leading into 2024, is the complexity of payer contracts,” says Ibrahim. A typical provider may manage hundreds or thousands of contracts, each one with a range of plans and provisions that affect the bottom line. “Being able to negotiate better contracts is a key concern,” says Ibrahim, “but clients increasingly feel outgunned and overwhelmed by the amount of information involved.” Accessing and analyzing data effectively is more critical than ever. “When providers come together with payers to negotiate contracts, it can be difficult for them to evaluate the contract that the payer is putting in front of them,” in part because it's hard to know how their current contract is performing or how contract provisions will play out in dollars and cents, Ibrahim explains. “Underpayments and denials are a constant struggle. Also, providers need to understand how volume and patient mix will factor in.” Contract management has a direct effect on revenue and the bottom line. Negotiated terms may or may not cover actual costs. A small change in terms might have an outsized effect due to high volume. Denied claims, underpayments, downcoding and late payments can slow the revenue cycle and reduce the amount of revenue providers receive. “At the same time, we're also starting to see a greater interest in collaboration between providers and payers,” says Ibrahim. “Having additional visibility allows both parties to have more meaningful discussions and move toward solutions that work for everyone.” Q2: What are providers doing to take on these challenges? “Many providers are investing in technology,” says Ibrahim. “A 2023 analysis by Bain & Company found that 80% of healthcare executives had accelerated software and IT investment over the past year in response to mergers and acquisitions, staffing shortfalls, and an increasing need for efficiency.” As contract management becomes more complex, providers are also reaching for more powerful healthcare contract management software tools to manage data—and leverage it to negotiate contracts effectively and monitor contract compliance over time. Q3: How can healthcare contract management software like Experian Health's Contract Manager and Contract Analysis help providers negotiate better contracts? “Having meaningful information backed by data changes the dynamic,” Ibrahim says. “It allows you to have a more strategic conversation. You can say, 'You're supposed to pay us 45 days from the receipt of the claim, but it's been taking 140 days.'” Data provides objective information and can point the way toward measurable improvements going forward. “Our Contract Analysis module allows for the provider to audit payer contract performance,” says Ibrahim. That's not only helpful for tracking what's happened to date; it's also useful for projecting how a new contract might work going forward. “We're able to use historical claims to create scenarios that show how a new contract would affect payment. Sometimes, payers will keep reimbursement rates the same where you have a lot of volume and give you an increase where you don't. When you use our solution to run these types of analyses, you get a more effective understanding of proposed terms.” Q4: Once contracts are in place, how can healthcare contract management software help providers improve compliance? “Detailed analysis is key, and small discrepancies can have a significant impact,” says Ibrahim. “One of our clients, a large academic provider on the medical group side, spotted a trend where they were being underpaid by 10 cents to 50 cents on their EKGs. These kinds of variances typically go unnoticed, but they found 20 or 30 claims to submit.” The payer acknowledged the underpayment and issued the few dollars' difference. “Then the provider decided to look at their contract to see how far back they could appeal. It turned out they were able to go back a significant amount of time. When they added up the underpayments, it equated to $850,000. They ended up settling for $750,000,” Ibrahim says. OrthoTennessee, a Knoxville-based orthopedic practice with multiple locations and more than 50 physicians, uses Experian Health's Contract Management software for healthcare to find inaccuracies, make appeals, and audit contracts at scale. Using Experian Health's Contract Management platform, OrthoTennessee had an 86% success rate for appeals in 2022. “That's the power of the solution: You can really identify trends,” says Ibrahim. Monitoring compliance is a continuous effort: “We’ve done a lot of work with our clients to understand what their evolving needs are. We’ve been named Best in KLAS [by healthcare IT research firm KLAS] multiple years in a row. That recognition has centered around engagement—being engaged with our clients, so we understand what the trends are, what challenges they’re facing, and how we can help solve problems in the most efficient manner.” Q5: What role do regulations play in shaping contract management solutions? “Regulation drives different reimbursement methodologies, [such as] bundled payments or value-based care,” says Ibrahim. “Part of our challenge is making sure we are always evaluating new regulations and ensuring that our system is agile enough to support these new methodologies. “Because regulation never stops, it actually drives a lot of the innovation we do. The No Surprises Act, which came into effect in 2021, requires providers to provide patients with a good faith estimate of costs. We've been able to help clients establish an estimated median rate, which can be useful for estimates that involve non-contracted payers.” As an additional benefit, healthcare contract management software also helps providers spot opportunities. “One of our clients identified 26 plans with enough volume to support additional contracts,” says Ibrahim.  “Providers can even use these solutions to evaluate whether a market exists for a new piece of technology to deliver state-of-the-art care. Understanding performance is a powerful tool.” Q6: Early in our conversation, you said there was a growing interest in collaboration among providers and payers. What does it mean to take a collaborative approach in this context? “I think it's really important for providers and payers to have collaborative communication, to engage in productive conversations where they can work together instead of against each other,” says Ibrahim. “That's how we're going to deliver more integrative care and reduce costs. It’s how we’re going to arrive at coverage options that work for all parties, by developing good relationships between providers and payers. “For our part, Experian Health is continuing to expand Contract Manager to provide data analytics that clearly show the cost of care and the expected reimbursement for various types of services, so providers can evaluate contract performance, identify potential areas of improvement, and have meaningful conversations with payers. “At the end of the day, we all have a common goal: delivering appropriate care at the right time for patients,” Ibrahim concludes. “To progress toward that goal, payers, providers and partners like Experian Health are going need to work together.” These conversations start with a common set of data, so that everyone at the table understands where the opportunities to collaborate and improve may lie—and where the path forward may begin. Learn more about Experian Health's Healthcare Contract Management software and how it can help your organization negotiate and manage contracts effectively and efficiently, even in an increasingly complex environment.

Experian Health ranked #1 in Best In KLAS for our ClaimSource® claims management system and Contract Manager and Analysis product – for the second consecutive year. The rankings were revealed in the annual 2024 Best in KLAS Awards – Software and Services, published on February 7, 2024. The Awards recognize the top software and services vendors that are helping American healthcare professionals deliver the best possible patient care, based on feedback from thousands of providers. Experian Health topped the list in two categories: ClaimSource ranked #1 in Claims Management and Clearinghouse. This automated and scalable solution reduces denials and increases revenue through a single application. The addition of an artificial intelligence component this year (AI AdvantageTM) is helping providers cut denial rates to just 4%, compared to an industry average of more than 10%. Contract Manager and Analysis ranked #1 in Revenue Cycle: Contract Management. This product levels the playing field with payers by monitoring compliance with contract terms and recovering underpayments. It also arms providers with financial models of proposed contracts, so they can negotiate more favorable terms. Case study: See how Hattiesburg Clinic in Mississippi uses ClaimSource to automate claims management and reduce denials. The awards come as the industry grapples with ongoing staffing challenges and rising claim denials. In Experian Health's 2023 report on the healthcare staffing crisis, 100% of respondents saw staffing shortages affect revenue cycle management and patient engagement. As the pressure continues, revenue cycle technology offers a way to increase efficiency and improve financial performance.  “Healthcare professionals face immense pressures, ranging from financial strains to staffing shortages and the very real issue of clinician burnout,” says Adam Gale, CEO and Founder of KLAS Research. “We want to provide actionable insights that will ultimately alleviate burdens and enhance clinician success.” For Tom Cox, President of Experian Health, the awards reflect a continuing commitment to help providers optimize operations and patient engagement using data-driven insights and technology. “This recognition from KLAS recognizes our dedication to deliver innovative solutions that not only improve the financial health of providers but also the patient experience. Receiving this award two years in a row is an honor as we remain steadfast in our commitment to simplifying healthcare through technology.” Find out more about how ClaimSource and Contract Manager and Contract Analysis helps healthcare organizations increase efficiency and boost financial performance.

Several major healthcare operators reported major losses for 2022, as revenue growth failed to outpace increasing expenses. McKinsey’s projections for provider profit pools suggest a more promising outlook over the next few years, with the fastest growth expected in virtual and non-acute care segments. As labor costs rise, organizations are looking for ways to cut spending and increase cash flow. Healthcare contract management is a key area to focus on, as underpayments and denied claims can significantly impact revenue. A third of providers report up to 15% of claims being denied, and underpayments continue to remain a significant concern. Securing reimbursements at already-agreed rates can help healthcare organizations significantly benefit financial performance. Unfortunately, managing payer contracts is not a straightforward process. Payer regulations and policies are in constant flux, and providers often lack the insights to negotiate and monitor payer performance effectively. Implementing a contract management solution can help providers negotiate favorable terms, check payer compliance, and reduce the risk of denials and underpayments. Why is healthcare contract management so challenging? Multiply thousands of vendors by thousands of service providers and again by thousands of patient encounters – and the scale of the healthcare contract management challenge becomes apparent. An average health system deals with hundreds of different payers, each with its own policies, processes, and paperwork. This lack of standardization makes it difficult to process claims efficiently and ensure payer compliance with agreed terms, not helped by soaring patient volumes and increasingly complex claims. The growing resource burden means the payer-provider relationship is coming under strain. But the challenge begins even before the contract is signed. Providers split their focus between numerous clinical and financial objectives. In contrast, payers can concentrate their attention more fully on fee negotiations. There’s an inherent imbalance in the resources each party brings to the negotiating table. As a result, providers are often on the back foot and can end up signing up for less favorable terms. Without a robust approach to negotiating and managing payer contracts, providers will struggle to achieve full reimbursement for services rendered. They may submit claims that do not adhere to payer policies, and find claims are being denied or not paid in full. More accounts will end up going to collections, and patients may be exposed to the threat of balance billing. At the extreme, providers may be forced to undergo lengthy appeals processes or even resort to legal action. The challenge of underpayment is especially fraught in emergency care, where disputes around reimbursement for services provided by out-of-network physicians at in-network facilities are common. It pays to invest in provider-payer relationships The solution lies in improving payer-provider relationships.. Smooth contract negotiations, clean claims and fair reimbursement rates are only possible when each party is clear about what they need from the other and delivers what they have agreed. By promoting better communication, transparency and accountability, providers can catch more underpayments and ensure more claims are clean the first time, leading to better financial performance. With a reliable contract management solution, providers can monitor payer compliance with contract terms and clarify what’s expected to ensure clean claims every time. Contract Manager and Contract Analysis: best in KLAS for healthcare contract management The 2023 Best in KLAS report identified Experian Health’s Contract Manager and Contract Analysis products as #1 in Revenue Cycle, Contract Management. This solution leverages Experian’s data, analytics, and technology to help hospitals and health systems improve contract management and financial performance in three ways: 1. Validating reimbursement accuracy Contract Manager helps providers find inconsistencies between amounts claimed and amounts paid. It accurately adjudicates each claim and compares expected payments to actual reimbursements. By continuously monitoring payer compliance with agreed contract terms, the tool identifies patterns of non-reimbursement to improve denial prevention and avoid missed revenue opportunities. Administrators can monitor reimbursement using online dashboards and real-time variance reports, which make it easy to manage multiple payer contracts and reimbursement methodologies. The tool also defines specific contract terms and fee schedules and can adapt to changing payer policies, to ensure that claims are processed and valued in line with current payment rules. 2. Preventing and recovering underpayments One of the biggest advantages of automation is the ability to find patterns that a human eye might miss (or take longer to spot). Manual processes (often based on a patchwork of Excel spreadsheets) are not only labor-intensive and costly, but do not consistently identify payment errors. Contract Manager offers a standardized approach to underpayment analysis, identifying sources and patterns of errors so recurring issues can be avoided in the future. Administrators can also use Contract Manager to generate data to support contract-based appeals, so they know which claims to appeal and can communicate more effectively with payers. 3. Negotiating favorable terms with payers Contract Manager’s automated system enables better management of collections data, payer performance and under-or over-payments. This puts providers in a stronger negotiating position when modeling new and amended contracts – a process that can be further improved with Contract Analysis. Contract Analysis assesses the potential financial impact of proposed contract terms down to individual service lines so providers can tailor their negotiation strategy to maximize reimbursement. It arms providers with real-world “what if” scenarios to provide insight into how contract terms could affect cash flow before they sign on the dotted line. Using real claims data to evaluate payer proposals gives providers insight into the true impact of proposed terms on reimbursement. It accelerates the negotiation process and gives providers leverage with payers that they might not otherwise have. Since the responsibility for proving that a claim has been wrongly denied or underpaid lies with the provider, it is on providers to make sure that agreed terms are favorable and to understand how they will ensure compliance. With Contract Analysis, they can reduce contract risks and prevent issues before they arise to drive down denials and underpayments. Using a healthcare contract management solution As the healthcare industry evolves, providers need to find ways to maintain resiliency and financial success. Healthcare contract management is an area where providers can make a significant impact on their financial performance. Unfortunately, managing payer contracts is a complex system with fluctuating regulations and policies. A dedicated contract management solution can help reimbursements maximize reimbursements and can provide the data insights providers need to efficiently negotiate better payment terms. Learn more about how Experian Health’s healthcare contract management solutions help providers improve contract negotiations, monitor payer compliance and recover more revenue.

Experian Health is very pleased to announce that it ranked #1 in Best in KLAS, Software and Professional Services, for two segments:  #1 in Claims Management and Clearinghouse, for our ClaimSource® claims management system  #1 in Revenue Cycle, Contract Management, for our Contract Manager and Contract Analysis product.   According to KLAS CEO Adam Gale, “The 2023 Best in KLAS report highlights the top-performing healthcare IT solutions as determined by extensive evaluations and conversations with thousands of healthcare providers. These distinguished winners have demonstrated exceptional dedication to improving and innovating the industry, and their efforts are recognized through their inclusion in this report. Congratulations to all the winning vendors for setting the bar for excellence in healthcare IT! KLAS continues to be committed to creating transparency and helping providers make informed decisions through our accurate, honest, and impartial reporting.”  Experian Health’s 2022 State of Claims survey reveals that 47% of providers said that improving clean claims rates was one of their top pain points, with 42% reporting that denials have increased in the past year. Read how Hattiesburg Clinic in Mississippi, which uses both Contract Manager and Analysis and ClaimSource, leverages ClaimSource to automate claims management and reduce denials. Learn more about how ClaimSource and Contract Manager and Contract Analysis can help your healthcare organization. 

In the sixth article in our series on how the patient journey has evolved since the onset of COVID-19, we look at three ways to prevent claim denials and reduce the time to payment. Faster claims processing is at the heart of a better patient financial experience and reduces revenue leakage for providers. For more insights and strategic recommendations to improve the patient journey in 2021 and beyond, download the full white paper. Nearly seven in 10 healthcare leaders say claim denials have increased in 2021, with an average denial rate of 17%. Inefficient claims processing and claims management systems were already struggling, but the pressures of the pandemic are causing even more rejections. Vaccination programs, rescheduled electives, and residency relocations contributed to fluctuating patient volumes, putting extra strain on reimbursement workflows. Patients switching health plans, and missing codes for COVID-19 vaccinations and treatment caused further delays and errors. Payer rules for reimbursement of treatment for “Long Covid” remain unclear: the absence of research and standards means claims are rejected because there’s no agreed “medical necessity.” Slow processes, incorrect patient identities, and poor data management mean the upward trend in claim denials seen over the last five years shows that it is likely to continue. Denials create a fragmented experience for patients because they don’t know how much they’ll need to pay for care, and leaves providers battling to recoup revenue. An effective claims management system is critical for maintaining provider revenue, securing patient reimbursements, and promoting positive patient-provider relationships. Here, we recommend a three-part strategy that uses data and automation to get claims right the first time. Prevention is better than cure One of the primary frustrations for claims management teams is that the majority of denied claims are preventable. Many of the errors that trigger denials could be avoided if databases and records systems could talk to each other. Instead of a reactive response, providers should invest in tools that can proactively prevent mistakes and errors, to ensure they collect every dollar owed. Digital tools can analyze data to help providers weed out the vulnerabilities in their processes and keep up with payer changes. Incorporating such tools is a sensible first step toward reducing and recovering expenses. One option is ClaimSource, which helps ensure that all hospital and physician claims are clean before being submitted to a government or commercial payer. It unlocks access to extensive federal, state, and commercial payer edits, allows custom provider edits, and incorporates automation tools and customer support. Providers can become confident that their claims will be correct the first time. Improving the likelihood of approval is critical to provider profitability and makes for a smoother patient experience. Prioritize eligibility checks for cleaner claims the first time Experian Health’s revenue cycle management experts say that the number one reason for denials is inaccurate eligibility. A 2020 poll by the Medical Group Management Association (MGMA) backs this up: 42% of providers said inaccurate or incomplete prior authorizations were a top cause of denials. Most providers use a medical claims clearinghouse or have systems to check eligibility beforehand. However, if patient identities aren’t verified properly at every touchpoint in the healthcare journey, mistakes can creep in and cause confusion about eligibility. Similarly, if the patient needs additional treatment that isn’t covered in the initial authorization, the resulting mismatch could lead to a denial. Tools such as Prior Authorizations and Insurance Eligibility Verification can help providers validate patient coverage in under 30 seconds. These solutions integrate with ClaimSource to fill in the gaps of patient information and streamline the claims process. Patients will get better insights into what they owe, and providers can increase efficiency. Automate workflows to eliminate time-consuming errors with claims processing Providers are well aware that manual processing slows reimbursement and increases the risk of errors. Tools such as Prior Authorizations and Insurance Eligibility Verification can help by using data and automation to improve accuracy and efficiency. The Council for Affordable Quality Healthcare suggests that automation can shave 20% off claims processing times, which could translate to thousands of hours saved each month. With those extra hours, claims teams will be freed up to complete their lengthy to-do lists and focus their efforts on other priorities. In addition, automated workflows can help assign work to the right specialist, keep track of payer changes, and incorporate repeated identity verification checks to drive down denials. With a Denial Workflow Manager, providers can automate and optimize their entire denial management process to get real-time insights on denied claims. This system can eliminate manual reviews and quickly identify accounts for resubmission or appeal. It can be integrated with tools such as ClaimSource and Enhanced Claim Status, so providers can monitor claims, denials and remits on the same screen and accelerate the workflow. As the pandemic continues to pressure profits and patients come to expect more from their healthcare journey, it’s no longer reasonable to accept denials as a cost of doing business. To find out how Experian Health can help your organization reduce denials, recover pandemic losses, and improve the patient experience, contact our team today. Missed the other blogs in the series? Check them out: 4 data driven healthcare marketing strategies to re-engage patients after COVID-19 How 24/7 self-scheduling can improve the post-pandemic patient experience COVID-19 highlights an acute need for digital patient intake solutions Automated prior authorization: getting patients the approved care they need Getting a holistic picture of patients with social determinants of health

    Many thought the end of COVID-19 was in sight with the availability of a vaccine, and while that is somewhat true, an entirely new set of issues has arrived: how to properly administer and manage the vaccine. Now that a COVID-19 vaccine is approved and underway, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. We interviewed J. Scott Milne, senior director of product management at Experian Health, about what’s changed and what providers can do to prepare. How can providers ensure that vaccine administration codes are billed correctly? The ICD-10 and CPT codes for the COVID-19 vaccine haven’t existed until now, which means providers have a new set of codes to learn and unfortunately, those codes seem to change or update almost daily. As more vaccines are introduced, more codes are also introduced, and not just for the vaccine as a whole, but for each specific dose of the vaccine. For example, dose one of the Pfizer vaccine will have a code that differs entirely from dose two of the Moderna vaccine. Keeping up with these changes isn’t only difficult for provider staff, who are likely already stretched thin, but they certainly don’t want to run the risk of submitting a claim with incorrect information. The errors are what result in denials or undercharges. A solution like Claim Scrubber ensures code sets are current on a daily basis – a necessity for times like these – but applies an extensive set of general and payer-specific edits before preparing the claim for processing. That means claims for vaccine administration are error-free before submission to the payer or clearinghouse. Providers can eliminate undercharges, boost first-time pass through rates and do away with costly, time-consuming rework. But proper coding is only the first piece of the billing puzzle. The second piece is to verify the accuracy of payment received from third-party payers. How can providers ensure that third party payers will reimburse at the contracted rates? Providers can certainly get reimbursed for administering the vaccine, but there are a lot of moving parts to keep up with. For example, both Medicaid and Medicare will reimburse providers for administering COVID-19 vaccines, but the percentage of what is covered will differ by carrier and the reimbursement rates can vary both by state and type of arrangement. Reimbursement rates will also vary amongst private payers. Then there is the variation in reimbursement based on vaccine type and dosage -- vaccines that require a single dose may be reimbursed at a rate different than those that require two doses. Even without the vaccine rollout underway it can be a headache for hospitals and health systems to manage multiple payer contracts and reimbursement methodologies. A solution like Contract Manager will pinpoint variance in reimbursement quickly and easily, accurately pricing claims and comparing actual allowed amounts to expected amounts. It is a tool built to adapt to changes within the industry, so providers can capitalize on emerging reimbursement schemes and changes in payer payment policies. It can also help identify sources and patterns of errors so recurring issues can be promptly resolved. The end result: the provider organization can the payer revenue that is due for vaccine administration. Interested in learning more about how providers can optimize vaccine-related reimbursements?   Other blog posts in this series: Segmenting your patient population for the COVID-19 vaccine Engaging patient segments with convenient, secure scheduling solutions Authenticating portal access with automation Optimizing reimbursements by capturing missing coverage