Hospitals and health systems across the United States are facing unprecedented rates of claims denials, negatively impacting their revenues and straining relationships with payers. These denials lead to multiple challenges, including increased administrative costs, resource allocation issues, risks to patient satisfaction, and the need for sudden process alterations to keep up with changing payer requirements.
The situation is exacerbated by antiquated denial processes from some payers, causing frustration and delays. Simultaneously, payers are leveraging automation to deny claims faster, creating a vicious cycle that providers struggle to keep up with.
To address these challenges, organizations are turning to AI-powered tools for denial prevention and management. These tools can detect patterns of denials and automatically address underlying issues without allocating additional staff. However, successful implementation of AI depends on selecting the right use cases and ensuring proper integration within the organization’s unique “DNA.”
Beyond AI technology, providers also need specialized expertise to fend off the bulk of denials. Payers are increasingly shifting the burden of proof for medical necessity and claims appeals to providers, requiring involvement from both clinicians and attorneys. This shift is pulling healthcare professionals away from direct patient care.
To streamline solutions to these challenges, hospitals and health systems are turning to specialized vendors with expertise in managing complex claims denials. These vendors, like Aspirion, offer a combination of AI technology and human expertise, including attorneys and clinicians, to handle a high volume of appeals. This approach allows internal teams to focus on improving processes upfront and mitigating future appeals.
Read full Becker’s Hospital Review article.