Product Overview: Experian Health AI Advantage
Experian Health’s AI Advantage is a cutting-edge, AI-powered solution designed to transform and optimize the healthcare insurance claims management process, particularly focusing on reducing and managing claim denials.
Purpose and Impact
AI Advantage addresses one of the most significant challenges in healthcare revenue cycle management: the increasing volume of insurance claim denials, which can lead to substantial financial losses and administrative burdens. By leveraging artificial intelligence, this solution helps healthcare providers mitigate these issues, streamline their claims processes, and maximize revenue.
Key Features and Functionality
AI Advantage – Predictive Denials
This component proactively identifies claims that are at a high risk of being denied before they are submitted. Here are its key functionalities:
- Real-Time Insights: Evaluates each claim and provides insights within the existing workflow systems to determine which items on the claim are likely to cause denial.
- Pre-Submission Editing: Allows providers to edit and correct claims prior to submission, reducing the likelihood of initial denials.
- Customizable Alerts: Offers tailored AI modeling and customizable alerts based on various criteria, including Claim Adjustment Reason Codes (CARCs), probability of denial, payer, or dollar amount.
AI Advantage – Denial Triage
This component focuses on managing denied claims efficiently. Here are its key functionalities:
- Post-Denial Analysis: Uses predictive algorithms to evaluate the probability that a denial will be overturned, integrating these probability scores into existing work queues.
- Prioritized Resubmissions: Identifies and groups denials most likely to be approved after resubmission, allowing providers to focus their efforts on the most valuable claims.
- Efficient Resource Allocation: Helps providers prioritize their rework on denied claims, reducing administrative burdens and the time spent on low-value denials.
Implementation and Integration
AI Advantage can be implemented separately or in combination for both pre-claim submission and post-denial processes. It is fully compatible with Experian Health’s ClaimSource® claims management system, which has been ranked #1 by KLAS in the Claims Management and Clearinghouse category for 2023.
Benefits
- Reduced Denials: Proactively identifies and corrects potential issues before claim submission, leading to a reduction in denials. For example, Schneck Medical Center reduced denials by an average of 4.6% each month after implementing AI Advantage.
- Increased Efficiency: Automates tasks and reduces the time and resources required for manual claims processing, allowing corrections to be processed in under 5 minutes compared to the previous 12-15 minutes.
- Improved Revenue Cycle Management: Helps healthcare providers maximize revenue by ensuring claims are paid faster and with greater accuracy, addressing the significant financial impact of denied claims which can amount to over $250 billion annually.
- Enhanced Patient Care: By streamlining the claims process, healthcare providers can focus more on delivering high-quality patient care rather than managing administrative burdens.
In summary, Experian Health’s AI Advantage is a robust solution that leverages AI to prevent and reduce insurance claim denials, enhance efficiency, and improve revenue cycle management, ultimately contributing to better financial health and patient care for healthcare organizations.