How AI Denial Management Can Reduce RCM Revenue Loss

Healthcare is changing, and it is in the transition stage where every little aspect of it has been intertwined with its change. You see, as the transition phase to value-based care has become the need of the hour, and as healthcare practices are making an effort to successfully transition it, the inefficiencies have been leading to significant financial losses.

A keen example of this can be seen in the rising rejection rates for insurance claims. An article from the Healthcare Finance News suggests that the claims rejection rate is as high as 10-15%. This somewhere indicates why healthcare practices have been desperate to improve their processes and make their practice profitable.

Being a healthcare IT professional, every practice I interact with is somewhere struggling with denial management. There have been some RCM automation tools that can help them mitigate the damage, but still, the gap is simply too huge to overcome so easily.

So, what can be done?

Well, rather than just addressing the problem by scratching the surface, why not change the approach and have something that could be an assistant to your workforce?

AI denial management software or claims denial AI agents can be a great solution to this. It can not only streamline your entire process but also automate it. Moreover, the benefits don’t just stop here; they simply extend with newer innovations.

Wondering how? Well, let’s explore how AI denial management software can reduce the denial rate for your practice.

The Denial Crisis: Understanding Revenue Loss Root Causes

Before getting into the intricacies of RCM automation tools improving your revenue cycle, let’s first understand why there has been a claims denial crisis.

To begin with, upon just looking at the practice’s databases, some of the top reasons for claims denial have been prior authorization, patient eligibility, coding errors, and documentation issues. While the list has been quite long, these issues were persistent and, with a streamlined process, could majorly solve most of your problems.

Other than that, if you’re a specialty practice, then the denial rate could possibly vary from other specialties or generic practices. Now, this varies because imagine the time your healthcare staff loses, the rework that your staff has to do for each denied claim, and most importantly, the impact it creates on the cash flow for your practice.

All of these things are connected, meaning as one thing is affected and falls, the domino effect takes place, and slowly, it starts affecting the other aspects of your practice.

AI-Powered Early Detection: Preventing Denials Before They Happen

This sub-title might sound a little clickbaity, but it somewhat is. This is because if you cannot predict the denial of a claim, at least you can do everything right just so the clearing houses cannot deny the claims. In other words, with denial pattern analysis AI, the problems in the claims you’re submitting can be easily identified, and that could possibly prevent denials.

Let’s see how:

1. Predictive Analytics for Denial Risk: This is particularly an application of AI-powered applications in RCM performance AI. For instance, this AI software can analyze the historical data of your patients and look for patterns in the most common denied claims. This will help you identify high-risk claims before submission.

2. Real-time Eligibility & Authorization Verification: Patient eligibility and authorization verification are the aspects that go hand in hand and together make a significant portion of denied claims. To overcome this, you can use automated insurance verification and prior authorization management tools to verify patient eligibility and authorization in real time.

3. Intelligent Claim Scrubbing: Another AI-powered innovation that we have been working on is auto-claim correction software. This is specially designed for claim reviews and identify inconsistencies in it before submission.

4. Proactive Correction Workflows: Another extension of this auto claim correction software is that it can automatically route the potential issues to the appropriate staff with suggestions to make the claim mistake-proof.

Intelligent Resolution: How AI Accelerates Denial Processing

If a claim gets denied, the process doesn’t stop there. Actually, it’s just a gateway to more work for your staff. It involves identifying the mistakes, then ratifying them, and submitting them again. It is actually a tiring and time-consuming process. That is why AI insurance appeals and denial resolution automation can help you with this. Let’s see how:

1. Automated Denial Classification: When your submitted claim is denied, there are certain reasons behind its denial. While manually analyzing can take up most of your time, you can instead use denial pattern analysis AI. This way, the AI can automatically categorize all the denials by type and complexity, and EOB GenAI would recommend the changes that need to be made for a successful claim.

2. Smart Appeal Generation: EOB GenAI is a type of application of AI insurance appeals, which will allow you to create appeal letters with personalized arguments and supporting documents to support your claims. This way, you can have proof, just in case a claim is wrongly denied.

3. Multi-Channel Communication Management: Communication when the claim is denied is essential. It involves collaborating with the payer and other players in the process. In such cases, AI denial management software can automate follow-ups with payers via phone, portal, or email. This way, you can ensure everything is streamlined and on track.

4. Escalation Intelligence: AI-driven decision-making about when to escalate and deny the claim or when to resubmit the claim can be extremely useful. Furthermore, with EOB GenAI, you can further extend its use case with writing off claim functionality.

Performance Analytics: Measuring Success with AI-powered Insights

To be honest, having an AI-powered RCM automation tool will ease most of your work, but if you’re not using it properly, then it’s probably for no use, right? Well, that is why when you have an AI, you just need to analyze its performance and make the most out of it. Let’s see how you can do it:

1. Determine Key Performance Indicators (KPIs): Well, to understand how your AI is performing, you need to identify some key performance indicators. To nudge you in the right direction, you can choose a clean claims rate, first-pass resolution net collection rate, etc. Once you identify these metrics, other things become easier, and finding the problem becomes easier so that you can find other solutions.

2. Predictive Revenue Forecasting: Since AI will be at the center of your entire financial process, it can easily predict revenue forecasts. For instance, take cash flow; the AI can easily analyze the partners in denial trends and resolution patterns and provide you how the future cash flow will be in your practice.

3. Payer Performance Analysis: Along with analyzing the performance of your practice and staff, AI can also analyze how your payers contribute to your practice’s finances. With detailed insights into payer-specific denial patterns and negotiation opportunities, you can add credibility to your payers.

4. Staff Productivity Metrics: Last but not least, with the RCM performance AI, you can easily measure the efficiency gains with AI automation and identify which processes work the best with lower claims denial rate.

Integration Strategy: Connecting AI to Your Existing RCM Stack

Integrating claims denial AI agents or AI denial management software with your practice management software is easier said than done. While your healthcare AI development partner would be of help, here is how you can ensure you’re not just kept in the shadows:

1. EHR & Practice Management Integration: Your practice management software and EHR are the cornerstones of your healthcare practice. Since most of the things revolve around these two systems, establishing seamless connectivity between them for your AI system makes sense.

2. Clearinghouse & Payer Portal Connections: Claims submissions and tracking the status of your claims are something very crucial. While many seem to ignore it, just the status can say a lot about your entire practice. It is because of this system integration that connecting the dots and making sense becomes much easier.

3. Implementation Methodology: The claims denial AI agent seems like a small part, but in reality, a lot of small parts come together. That is why choosing to opt for a phased rollout approach can minimize disruptions and maximize the adoption success rate for your practice.

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