Key Points:
- Hospitals are experiencing a surge in denied insurance claims, leading to a loss of revenue.
- Claims denials have increased in recent years, with an average denial rate of 17% for insurance companies.
- There is a shortage of talent and expertise in denials management, making it difficult for hospitals to fight against denials.
- The use of AI-powered denials management has the potential to streamline claims processing and improve coding accuracy.
Many hospitals are facing significant challenges in managing denied insurance claims as part of the revenue cycle management (RCM) workflow. Insurance companies are denying a substantial number of claims, with an average denial rate of 17% for in-network care. This is causing a loss of revenue for hospitals, especially as the dollar value per denial and the resolution times for claims have increased. Additionally, hospitals are facing a shortage of talent and expertise needed to navigate the complex denials landscape.
Artificial Intelligence (AI) has the potential to revolutionize the denials landscape by streamlining claims processing, enhancing coding accuracy, and extracting essential information from medical records and payer contracts. AI can automate workflows and prioritize accounts to increase yield. Experienced revenue cycle professionals play a crucial role in denials resolution and prevention, but the integration of AI can empower them to operate more efficiently and effectively.
One key application of AI in denials management is the use of selection models. These models are designed to choose or classify specific items or entities based on certain criteria. In the context of denials management, selection models can help automate the prioritization of accounts to increase yield. By using AI, hospitals can identify and focus on high-value claims that have a higher likelihood of being overturned.
Another application of AI in denials management is the use of predictive analytics. AI can analyze historical claims data and identify patterns or trends that can help predict future denials. By understanding the root causes of denials, hospitals can take proactive measures to prevent them from occurring in the first place.
Overall, AI-powered denials management has the potential to significantly improve the revenue cycle management process for hospitals. It can help address the challenges of rising costs, labor shortages, and declining operating margins by streamlining claims processing and increasing yield. By harnessing the power of AI, hospitals can navigate the next big shift in revenue cycle automation and ensure their financial stability in an increasingly challenging healthcare landscape.