Reduce Claim Denials through Process Automation

Health systems of all sizes continue to face expensive claim denial issues, and the rate of claim denials has steadily risen since 2016. The pandemic only worsened the trend; by the third quarter of 2020, the initial claim denial rate had reached 11%. This indicates that more than one in every ten claims is rejected. Practices are losing significant revenue because the vast majority of these denials can be avoided or corrected. Why does this issue keep getting worse? Claims management is becoming more and more challenging due to the numerous complexities in the procedures and laws, and most health systems heavily rely on human resources rather than technology. But adding more workers will only address the underlying issues if human workforces are already overburdened.

The good news is that today’s solutions to lower claim denials and deliver a profit are powered by automation and artificial intelligence. To successfully implement robotic process automation in healthcare, it is important to consider where automation can add value, what resources are available to help, and whether a partnership can speed up the process with additional skills or resources. There are opportunities to use artificial intelligence at every stage of the practice revenue cycle to prevent expensive denials. AI can reduce human error, lengthen staff claim processing time, and offer insightful denials management advice, all of which reduce revenue loss and enhance the practice’s cash flow and cash management. Robotic process automation has also proven extremely effective in improving patient experience.

 This is how:

1. Ensuring Correct Eligibility

Errors and inefficiencies can occur from the very first patient interaction, leading to downstream problems. Ensuring accurate eligibility by using AI to automate benefit verifications has a positive ripple effect throughout the revenue cycle, including reduced denials. Many of these result from coverage changes between initial scheduling and the appointment or inaccurate benefit information being pulled into the EHR. Intelligent automation can supplement your existing EDI real-time eligibility checks by checking coverage more frequently and reducing errors in benefit pulls, resulting in fewer denials due to inaccurate or out-of-date benefit information.

2. Automation Can Help Improvise Your Patient Collection

To better care for patients, the healthcare sector is developing to accommodate remote healthcare. Due to the pandemic’s high demand for healthcare workers, there is a desire to automate procedures and relieve the strain on overworked healthcare providers. The biggest care gaps can be closed by increasing the number of healthcare professionals in every facility and easing the workload on those already there. Automation of procedures is the best way to improve care while earning enough money for providers and private healthcare facilities.

3. Checking the Status of Claims

Claim status checks are an important part of healthcare claims management, but they are only sometimes a value-add. Frequently, the claim status is checked, and no further action is required. However, manually checking a claim’s status takes 14 minutes. When the number of claims and the frequency at which the provider would check them optimally are considered, it is clear that this is impossible for humans to accomplish. Because it is a simple, repetitive task, it is an excellent candidate for automation. But how does this reduce denials? Most revenue cycle departments need to catch up on claims, with no time to rework denials that could be recovered or improve other revenue cycle processes that would prevent denials in the first place. Currently, 48% of claim rejections and denials go unworked. So, while automating claim status checks does not reduce denials in and of itself, it does save a significant amount of staff time that can be redirected to other steps in the revenue cycle process, such as reworking denials.

4. AI-Powered Denials Management 

After a claim is denied, artificial intelligence can assist healthcare systems in recovering more of these claims. The above-mentioned automated claims status checks are the first step in an AI-powered denials management system. When a claim is marked as “denied,” artificial intelligence can automatically correct any minor mistakes and resubmit the claim. AI can route the denial to a human for more complex errors while providing detailed patient and denial information, greatly reducing rework time. An AI-powered denials management system will work denials and collect all available reimbursements, boosting revenue and lowering days in A/R.

5. Insights into Denials from Deep Learning  

Unlike simple RPA solutions, artificial intelligence can analyze the data behind claims processes and uncover actionable insights. One health system, for example, discovered that one specific drug denial resulted from missing prior authorizations and medical necessity. With this information, the hospital could pinpoint and resolve this recurring problem. Process improvement opportunities are hidden in your organization’s daily data; you need AI to find them.

Benefits of Fully Automating Your RCM Processes

Automating the revenue cycle processes can speed up billing, reimbursements, posting payments, and accounts payable and accounts receivable transactions. By doing so, manual data entry errors caused by people can be eliminated, improving forecasting and revenue cycle management (RCM) procedures.

• 60% Increase in Productivity
• 70% Increase in Quality
• 90% Operations Cost Savings
• 50% Decrease in Claim Denial Rates
• 30% Decrease in Regulatory Compliance Issues

Improve your denial and appeal management team to deal with claim denial issues.

• Denial and Appeal RPA offers process and workflow-enhanced denial management protocols for locating the primary reason for denials and appealing denied and underpaid claims.
• RPA bots examine ERAs and use rules to detect suspected payments and denials in the appropriate team or automated work queues.
• Reduces the need for manual consolidation of your denial reports when detecting aging, priorities with dollar values, and payers.
• RPA bots create KPIs based on HFMA MAP Key data. HFMA MAP Key provides quantitative management in which data is measured and used to drive improvement decisions.
• Protocols for RPA bots can be defined to guide each step of the denial or appeals process, eliminate missed deadlines, generate email notifications, and improve communication across the practice or medical group.
• Compared to hiring multiple denial management staff, there is a cost saving when producing paperwork and reports for consolidation.

Additionally, benefits of using robotic process automation (RPA) to automate your EHR include reduced errors, faster navigation, and tasks that previously required more manual labor hours.

Bottom Line 

This article demonstrates how robotic process automation can reduce claim denials in medical billing procedures. Robotic Process Automation (RPA) is a solution that employs microbots to automate routine revenue cycle management tasks. You can focus on more important revenue-generating activities. It is effective for claim processing automation. Based on a predetermined checklist, an RPA BOT can monitor outgoing claims. If an error pattern is discovered before the claim is submitted, the RPA BOT can take corrective action. Claims that the RPA BOT cannot resolve can be transferred to an exception flow path and queued for resolution by a human.