The Experian Health Denial Workflow (also known as Denial Workflow Manager) is a key component of Experian Health's Revenue Cycle Management (RCM) suite, designed to automate and optimize the tedious process of managing denied healthcare claims. It integrates workflow, enhanced claim status, remittance detail, and advanced analytics to streamline follow-up activities. The solution identifies denials, holds, suspends, and zero pays using Electronic Remittance Advice (ERA) and Enhanced Claim Status (ECS) transactions.
Key Capabilities and Benefits:
- Automation: Automates the denials process, eliminating the need for manual review of claim status and remittance advices to maximize reimbursements.
- Customizable Work Queues: Generates customizable work lists based on client specifications, such as denial category and dollar amount, for efficient activity tracking and final resolution.
- Analytics and Root Cause Analysis: Provides advanced denial analytics and reporting capabilities to identify denial patterns and determine the root causes across payers, procedures, and departments, informing improved procedures.
- Integration: Can be used as a standalone product or integrated with other Experian Health solutions like ClaimSource® to view claim and denial information on the same screen, allowing users to correct and re-submit a claim while working the denial.
- AI Advantage™: The product is enhanced by the AI Advantage suite, which includes Predictive Denials (using AI to flag high-risk claims before submission to prevent denials) and Denial Triage (using advanced algorithms to prioritize denied claims with the highest likelihood of a successful appeal overturn).
This technology is designed for medium to enterprise-level healthcare organizations, including hospitals, health systems, medical groups, labs, and pharmacies, to increase cash flow, reduce AR days, and decrease denial rates.