Editorials by Jorie

How Artificial Intelligence can Improve Healthcare Denial Management

The US healthcare denial management market is highly fragmented and competitive. The market is characterized by rapid technological change, including cloud-based medical billing management. Integration of electronic health records usage has revolutionized the claim denials process. Vendors continually develop new technologies to acquire and market new services to access a new set of consumers. Several competitors face competition from vendors of specialized software solutions that offer similar billing solutions at significantly lower prices.

Further, many established companies are acquiring or collaborating with smaller vendors, offering complementary products, technologies, or services to expand their presence in the market. Moreover, several key players indulge in mergers and acquisitions to remain competitive and expand their reach through inorganic growth strategies.

Artificial Intelligence & Denial Management

By applying AI and machine learning throughout the healthcare payment lifecycle, healthcare payers can virtually eliminate manual, burdensome tasks that can cause issues when filing claims. Artificial intelligence-enhanced automation allows an organization to capture actionable and meaningful data and interact with a wide array of payers to accomplish tasks in real time.

For example, let’s take a look at the prior authorization function. The preauthorization of patient care has long been considered a necessary evil in providing care and business operations spend an excessive amount of time and resources to process and follow up on the vast number of pre-authorizations required.

A criteria-based algorithmic system that can submit clean and accurate claims to payers will greatly reduce the denial management process at the back end of your organization's operations.

Optimize Cash Flow with AI Denied Claims Management

As healthcare organizations try to address the revenue leakage issues that denied claims cause, they have had varying success using technology and process-based solutions. And as the rapidly changing healthcare industry gets even more complex, denied claims can have multiple causes—given the ever-increasing number of insurance plans and products available—making it more difficult than ever to remediate denials.

A Back-End Problem Eliminated with a Front-End AI Solution

According to the American Medical Association (AMA), more than 91% of providers say that prior authorizations have a negative effect on patient care by impacting clinical outcomes and causing delays in treatment if not outright abandonment of care.

Using automation and AI-powered cloud-based technology to submit and update provider authorization requests directly from an EHR/EMR, payer authorization can be obtained in real time and appointments scheduled efficiently. A bi-directional integrated pathway allows automated status checks and updates to be communicated to staff through time-sensitive alerts and notifications.

By automating the process of prior authorization, claims will be processed more quickly and denied claims will be eliminated. Revenue will be captured in a timely manner, either through insurance payers or patients (if that’s deemed appropriate).The time previously spent on the prior authorization function can now be shifted to higher-level functions, improving the patient experience.

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