Our February blog post is going to introduce and outline our upcoming five-part series on claim denials. Experian’s Health Report for 2024 had nearly three out of four respondents stating their claims denials have gone up, versus less than half of respondents only two years ago. Almost 40% of the respondents said their claims are denied 10+% of the time, while 11% of the respondents received denials at least 15% of the time. Below are five focal areas which, if addressed, can lead to significant improvements for this pervasive issue.
AI & Automation for Claims & Prior Authorizations
AI-powered systems can analyze patient data, clinical guidelines, and payer requirements to automate the submission of prior authorization requests, significantly reducing processing time and administrative burden. In claims processing, AI can automate data entry and identify potential errors. In both cases AI can predict the outcomes; leading to faster and more accurate claims adjudication.
Real-Time Eligibility & Pre-Service Financial Clearance
Providers have the ability to verify a patient’s insurance coverage and benefits before services are even rendered, which helps prevent denials due to outdated or incorrect information. This can also identify any potential issues, such as the need for prior authorization. Pre-service financial clearance takes this a step further by assessing the patient’s financial responsibility; including co-pays, deductibles and outstanding balances.
Proactive Claim Denials Prevention & Appeals Management
By focusing on identifying and correcting potential issues before claims are even submitted, providers can significantly reduce the likelihood of denials before they have the chance to occur. When denials do happen, an effective appeals management process is crucial. This involves tracking denials, identifying root causes and efficiently submitting well-supported appeals.
Robotic Process Automation (RPA) for Administrative Workflows
RPA involves software “bots” that can automate repetitive, rules-based tasks such as data entry, claims submission, payment posting and even some aspects of prior authorization processing. This frees up staff to focus on more complex and strategic work, improving efficiency and reducing errors.
Patient Engagement & Financial Advocacy
Patient engagement can include providing clear & accessible information about treatment costs, payment options and insurance coverage, which empowers patients to take an active role in managing their healthcare expenses. Financial advocacy programs provide patients with further support by helping them navigate complex billing processes, appeal denial claims and access financial assistance resources when needed.
Stay tuned for next month’s deep dive into the use of AI and automation for claims & prior authorizations; and as always if there is a topic you’d like to see our blog cover feel free to let us know!