Increase the Success of Clinical Denials Appeals With AI!

Nearly three in four provider organizations say the top problem facing their revenue cycles – claims denials – is getting worse. In a Kaufman Hall report published last fall, 73% of respondents said claims denials were up in 2023 over the previous year.??

The cost of claims denials to healthcare providers is astonishing. In 2022 alone, providers spent nearly $19.7 billion on efforts to resolve delays and denials across payers. In more than half the cases (54.3%), providers eventually recovered $10.6 billion through successful appeals. But as any competent healthcare CFO will tell you, spending two dollars to recover one is not a viable long-term financial strategy.?

As Steve Albert, executive vice president and chief product officer of R1 RCM , writes in a recent byline published in HIT Consultant, claims denials produce a “cascading effect” on patients that negatively impact their experience as healthcare consumers.?

No patient-centric provider organization would want to add an unexpected financial burden to a person already trying to recover from recent surgery. But as we saw from the figures above, the process of appealing denied claims is costly, requiring a heavy reliance on medical professionals who have the clinical knowledge to make a strong case for reimbursement.?

Fortunately, as Steven Albert writes, providers today can leverage AI, automation, analytics, and other advanced technologies to streamline claims management processes and prevent denials.??

AI-enabled analytics also play a role in preventing denials by identifying trends based on payer, clinical indications, and other variables. This allows providers to focus on the denied claims that stand the best chance of being overturned. Further, Albert says, data generated by AI platforms can be continuously analyzed by providers to constantly improve claims processes.?

While the payoff to providers of AI tools is immense, some organizations may have to overcome internal adoption challenges that are common to disruptive technologies. Albert explores these challenges – and how healthcare organizations can overcome them – in his HIT Consultant byline.?

Read Steve’s full HIT Consultant Media article here.?We'd love to hear your thoughts! How do you think AI can further transform healthcare? Drop a comment below.

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