New AI-Powered Products From Experian® Health Will Help Healthcare Providers Recoup the Billions in Lost Dollars Due to Insurance Claim Denials
- Written by: iPMI Global
To address one of the most pressing problems in healthcare,i Experian® Health, a leading provider in revenue cycle products, announces the launch of AI Advantage™ to mitigate the increasingly high volume of healthcare insurance claims denials.
As the most seamless and comprehensive system for claims management in the healthcare industry today, the products leverage artificial intelligence (AI). Coupled with Experian’s expertise in big data solutions and insights, these all-new solutions will help healthcare providers prioritize their claims reimbursement process and decrease claim denials overall, saving time and money across the entire healthcare value chain and ultimately improving care and service for patient consumers.
One of the top contributors to wasted healthcare dollars is due to the claims process, reported at more than $250 billion per year.ii Additionally, 35 percent of hospitals and health systems report $50 million or more in foregone revenue as a result of denied claims once appeals have been exhausted.iii In fact, up to 65 percent of denied claims are never resubmitted.iv
Experian Health’s AI Advantage encompasses two products that optimize the current claims process through automation and arms providers with the real-time insights to avoid unnecessary denials with greater speed and efficiency. The two products can be implemented separately or combined for the pre-claim submission and post-denial processes:
- AI Advantage – Predictive Denials evaluates each claim and its likelihood of being denied while also providing insights back to the provider in their existing workflow systems to help determine which item(s) on the claim are the leading cause for denial before submitting. This allows the right specialist to intervene before claims go to payers with a “clean” submission. The product also leverages large-scale historic payment data tuned to providers’ denial trends for continuous learning and adaptation.
- AI Advantage – Denial Triage helps providers focus efforts on denials based on their potential and likelihood for yield, automating decision-making for providers. The predictive algorithm evaluates the probability a denial will be overturned and integrates the probability scores directly into existing work queues. This allows providers to focus their efforts on where they are most likely to have a positive result.
“Our mission is to simplify healthcare for all and claims management has been ripe for innovation using AI to greatly improve accuracy and efficiency,” said Clarissa Riggins, chief product officer for Experian Health. “This is an example of how we are using AI and analyzing and processing data to impact a pressing problem such as the claims denials crisis. There is no doubt that implementing AI Advantage, as well as the continued use of AI-powered products, will revolutionize the business of healthcare.”
Both products uniquely deliver tailored AI modeling and are fully customizable so providers can choose alerts based on a variety of criteria, including but not limited to Claim Adjustment Reason Codes (CARCs), probability of denial, payer or dollar amount.
Addressing claim denials with technology is an industry priority
Healthcare claims are denied for a variety of reasons, like incorrect coding, over-billing and lack of authorization by insurers. Each denied claim carries significant financial consequences for providers with additional paperwork and lost revenue, while patients potentially face unexpected out-of-pocket costs and disrupted care.
A recent report found that 33 percent of healthcare costs are associated with administrative tasks for providers. The benefit of AI is speed and accuracy when managing large amounts of claims data and it can identify issues that could lead to rejection or delayed payment, like missing information, wrong billing codes, incomplete prior authorizations or medical necessity criteria, helping to expedite processing time and alleviating staffing shortages.
By leveraging AI Advantage products, healthcare organizations can streamline the claim reimbursement process and better apply their resources to their ultimate mission in caregiving. This impact can trickle down to patients as well, preventing higher out-of-pocket costs as a result of a denied claim.
Unfortunately, the claims denials issue does not seem to be improving as it was reported that claim denials increased by 11 percent last yearv and, according to a recent Experian survey among healthcare executives, 30 percent of respondents say denials are increasing between 10-15 percent.
It’s no surprise that 72 percent of those surveyed say that reducing denials is the highest priority and a majority (78%) of respondents are also likely to completely replace their existing claims management system with new technology.
i Experian State of Claims Survey, June 2022; Harmony Healthcare Survey, 2021
ii Humana Study, 2019
iii Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers, American Hospital Association, November 2022
iv Callahan, M., “Strategic Denials Management: The Key to an Efficient Revenue Cycle,” RevSpring, blog, June 13, 2018
v Hospital double whammy: Less cash in, more cash out, Crowe LLP, November 2022
