Using AI Modeling to Prevent Claim Denials

Modern technology has made it possible for health care officials to use things like predictive analytics in order to improve collection times. For the most part, this technology has been used on standard billing, such as the claims sent to patients for their portion of the bill. However, it can help in the case of commercial health insurance claim denials. Predictive analysis is designed to point out certain payer trends and it will help hospital billing departments pick up on which of those commercial health insurance companies are most likely to not pay their claims. Even with this new technology, there still is a need for Federal ERISA appeals. Although the main amount of these appeals will go down, some are still necessary.

Revenue Cycle Management Using Technology

According to the experts, “Discussions around predictive analytics in healthcare are often centered on tech-enabled modeling to predict patient needs and behaviors with the aim of better care management, quality improvements, and population health initiatives. In the revenue cycle, modeling is also used to improve the patient’s understanding of their portion of the cost of care to help improve collections at the time of service.”

They go on to explain that, “Hospitals have used predictive data models to help improve patient collections however, the benefits that predictive analytics can bring to the revenue cycle don’t end with patient access. In recent years, hospitals have learned the value of using similar data models to assess a payer’s propensity to pay or deny claims.”

Finally, it helps when “Understanding the reimbursement patterns that payers have adopted around a variety of claim types allows an organization to leverage its revenue cycle workforce more strategically. For example, if it is known that a particular payer isn’t likely to remit payment for care delivery until day 14 (regardless of the claim type or when it was submitted), the team won’t be prompted to work an account until day 15 or 16. Organizations can use these insights to redirect the workforce to resolving more complicated accounts or performing tasks that require more critical thinking.”

No matter how this technology is utilized, there are still some conventions present in the standard billing cycle.

Claim Denials and State Level Appeals

Generally, a hospital billing department follows a certain pattern. The procedures and appointments are completed, the billing department goes over them and codes them, and then send out the claims to the commercial health insurance companies. However, claim denials, which can occur for many different reasons, from miscoded items to wrong patient identifiers, happen quite frequently. The health insurance company send the claim back unpaid, and it’s up to the billing department employees to go back over it and make any corrections (if necessary) before sending it back. This resending of the claim is called the first state-level appeal. The hospital receives three of these state-level appeals before they have to give up and accept (at first) that the commercial health insurance company isn’t going to pay up. At that point, it’s time for the Federal ERISA Appeals.

Federal ERISA Appeals Are Next

Federal ERISA Appeals are something that many hospital and health clinic CEOs have heard of but don’t really take advantage of. ERISA is short for the Employee Retirement Income Security Act. It’s a federal act that was originally designed to protect employee retirement accounts, specifically the ones that they pay into. Later on, this was expanded to cover employee health insurance as well. The plans that individual employees pay into are protected by this act, which is good news for those CEOs, as they can use Federal ERISA Appeals in order to collect on those claim denials.

The bad thing is the Federal ERISA law isn’t really covered in law schools, and the process for filing a claim on it is rather arduous. Billing department employees don’t have the time or the knowledge to deal with them. This is why a company that specializes in these claim denials must be contacted. You don’t want that money to sit around in your debt bucket.

It’s Time to Take Action

If the new AI modeling and predictive analytics haven’t helped and you’re still dealing with plenty of claim denials, it’s time to take action. We can help! Call us today. We can be reached at (972) 331-4140. We also have a contact form on our website. Just fill it out, and one of our experts will give you a call.