Regardless of elevated entry to claims administration expertise, claims denials are nonetheless on the rise in 2024. Contributing components embody rising healthcare prices, stricter payer reimbursement insurance policies, and claims processing errors. Suppliers are seeing an uptick in nonpayment, plus an added burden on administrative workers, disrupted affected person care, and hits to the underside line.
Experian Well being surveyed over 200 healthcare professionals, primarily in government or administration roles, to raised perceive the present state of claims. The findings of the State of Claims 2024 report break down the newest medical health insurance declare denial statistics, causes for denials, and suppliers’ considerations about reimbursement.
Rising healthcare prices: who will foot the invoice?
The U.S. healthcare system is the costliest on this planet, and prices proceed to rise. In 2022, healthcare spending reached $4.5 trillion, a threefold improve from $1.4 trillion in 2000. In 2023, prices rose 7.5% to $4.8 trillion. Paying for healthcare is turning into increasingly more out of attain for sufferers and inflicting nice concern. Over three-quarters (77%) of suppliers fear sufferers will skip out on their medical payments.
Payer reimbursement challenges are additionally weighing closely on healthcare leaders’ minds. Greater than 75% are anxious about nonpayment resulting from ever-evolving payer coverage modifications. Additionally they have considerations concerning the pre-authorization struggles which have continued since 2022, as reported within the State of Claims 2022 survey. Hospitals are notably feeling the monetary pinch of working inside such an costly setting and face uncertainties about assembly monetary obligations on prime of different main post-pandemic challenges like workers shortages.
The affect of claims denials
Suppliers proceed to see claims being denied in higher numbers. In 2022, 42% of respondents mentioned denials are growing. The quantity jumped to 77% in 2024. Equally, the time it takes to be reimbursed is growing, per 67% of respondents. That quantity was 51% in 2022.
In 2024, 84% of healthcare organizations will make decreasing denied claims a prime precedence. The Journal of Managed Care & Specialty Pharmacy studies that the burden of denied claims totals round $260 billion yearly. The affect of declare denials is far-reaching, affecting the affected person expertise and income cycles. Struggles with claims additionally burden workers and drain sources, contributing to much more losses.
The rising problem of information assortment, verification and authorization
Profitable claims processing will depend on accuracy. Nonetheless, attaining accuracy in information assortment, verification, and authorization processes stays a continued problem for claims administration groups. Practically half of respondents (46%) within the State of Claims 2024 report recognized lacking or inaccurate data as the first trigger for denial. Inaccurate or lacking information additionally creates further steps in claims processing, ensuing within the want for secondary checks and “wasted” healthcare {dollars}. Survey respondents reported utilizing a number of options to gather all the required affected person information for claims, with some utilizing as many as 4 totally different merchandise.
Leveling the taking part in area in claims administration with expertise
Staying on prime of reimbursement necessities and processes is complicated, resource-demanding and time-consuming. Inaccuracies commonplace with guide processing exacerbate points and additional lengthen processing and reimbursement occasions. Nonetheless, automation and AI expertise have confirmed efficient at decreasing claims denials and the burden of guide processing.
“Including AI in claims processing cuts down denials considerably,” Tom Bonner, Principal Product Supervisor at Experian Well being, explains. AI automation shortly flags errors, permitting claims modifying earlier than payer submission. It’s not science fiction—AI is the instrument hospitals want for higher healthcare claims denial prevention and administration.”
In the course of the pandemic, suppliers embraced new expertise to satisfy quick wants; nevertheless, that momentum slowed lately. In 2022, survey information revealed that 62% of suppliers have been utilizing some type of automation and AI expertise. But, in 2024, solely 31% mentioned they used this sort of expertise.
Right here’s how claims automation will help healthcare organizations enhance claims success charges:
Handle your complete claims course of: Utilizing an automatic, scalable claims administration system, like ClaimSource®, helps cut back denials and improve income. Suppliers can handle their total claims cycle in a single utility and guarantee claims are clear earlier than submission.
Submit extra correct claims: An automatic claims submission instrument, like ClaimScrubber, helps establish errors that sometimes lead to denials or underpayments earlier than submission. This leads to faster funds, much less time chasing aged accounts receivables, and improved money move.
Get rid of guide processes: Suppliers that use Denials Workflow Supervisor can goal claims that want consideration instantly, managing denials extra successfully and growing reimbursements considerably.
Enhance money move: Enhanced Declare Standing helps suppliers take an early-and-often method to monitoring declare standing within the adjudication course of. It eliminates guide follow-up duties, permitting suppliers to reply early and precisely to pended, returned-to-provider, denied or zero-pay transactions.
Forestall denials: Experian Well being’s AI Benefit™, an AI-driven platform, makes use of a company’s personal historic claims information, plus Experian Well being’s subtle information of payer guidelines, to constantly be taught and adapt to an ever-changing payer coverage panorama. This expertise helps suppliers higher predict and stop claims denials, give attention to high-priority claims, and increase total income.
Adaptation of expertise is probably going on the rise with 45% of healthcare leaders planning to put money into automation within the subsequent six months. Over the subsequent 12 months, these investments may repay if claims denials begin to lower in consequence, prompting extra healthcare organizations to spice up investments in claims administration expertise.
Obtain the State of Claims 2024 report back to get the newest medical health insurance declare denial statistics, or contact us to learn the way Experian Well being will help with higher claims administration.
