Claim denials have always been a huge challenge for healthcare providers. They not only result in huge financial losses but also negatively impact the revenue cycle in the long run. A recent report suggests that nearly 20 percent of all medical claims are denied. This alarming number calls for a proactive approach.
Here, the role of Artificial Intelligence (AI) comes into the picture. AI is a game-changer in the world of medical coding. Why? Because it enhances accuracy and streamlines workflow by automating the process of assigning accurate alphanumeric codes to the patient records. This ultimately helps healthcare providers get fully reimbursed for their services.
This blog will walk you through the main reasons behind claim denials and how AI is empowering healthcare providers to address this challenge proactively.
Identifying the Root Cause of Claim Denials
One of the main reasons behind claims getting rejected is inaccuracies in medical coding. Although medical coders are skilled and certified, they still have to go through more than 70,000 ICD-10 codes and over 10,000 CPT codes. Along with this, there are strict payer guidelines and compliance rules to follow. This can get overwhelming for any human, and errors are bound to happen. Even a small mistake can trigger a denial, resulting in appeals and lost revenue.
How is AI Revolutionizing Medical Coding and Denial Management?
- Automated Eligibility Verification
Did you know that inaccurate patient information is one of the top reasons for claim denials? AI offers the best solution: automated eligibility verification. AI tools verify coverage details upfront, ensuring accurate information for claims processing and minimizing errors. Any discrepancies or changes in patient eligibility trigger an alert, streamlining the registration process. This, in turn, improves efficiency and the financial stability of your practice. - Coding Accuracy Through AI-Powered Precision
AI uses natural language processing (NLP) to analyze unstructured data like physician’s notes, lab reports, imaging results, and more to identify every relevant element. Whereas a coder under time constraints might miss a secondary condition such as “nerve pain radiating from the spine.” AI doesn’t miss. It flags all these details and recommends accurate codes. The result? Fewer oversights = fewer denials. - Real-Time Error Detection + Prevention
In the era of AI, coders don’t have to constantly be on the lookout for mistakes in coding. AI tools like Aidéo Gemini™ perform real-time claim audits to identify issues as they arise. A mismatched diagnosis or an omitted modifier? An immediate alert such as “Verify supporting documentation for medical necessity” pops up, allowing coders to address it quickly. Such useful features can help in significantly lowering initial denial rates. - Staying Compliant with Guidelines and Policies
Payer policies are a web of complexities, where each insurer has its own rules. AI systems like Gemini™ make it easy for medical coders to stay compliant by maintaining a dynamic database of guidelines that keeps updating with any changes in the policies. AI tools evaluate claims against these standards, ensuring compliance. For instance, if a payer policy calls for additional documentation for a surgical procedure, AI will prompt an alert, suggesting coders include it. AI also uses historical denial data to highlight recurring issues to medical coders so that they can proactively adjust them and boost approval rates. - AI-Driven Appeals Process
AI can recognize patterns, and that’s what makes it so useful in terms of streamlining the appeals process. AI tools analyze past denials and payer trends to prioritize claims with higher chances of approval. AI-powered automation transforms the appeal process by identifying denial reasons, retrieving relevant documentation, and generating accurate appeal letters. Automated workflows ensure appeals are submitted promptly, minimizing delays and increasing the likelihood of successful reimbursement. - Automation = Less Workload and More Productivity
Manual medical coding involves a lot of repetitive tasks like categorization, triage, and appeal generation. AI-driven tools automate these mundane tasks and free up coders’ time to focus on more complex issues. AI systems effortlessly integrate with the RCM system, improving visibility into the RCM process, from claim submission to final resolution, supporting denial management.
The Future of AI in Medical Coding
As AI technology continues to evolve, its role in medical coding is only going to grow. Future achievements may include:
- Improved Predictive Analytics: In the coming years, AI is set to provide even deeper insights into billing trends and denial patterns.
- Greater Integration: Seamless integration with EHRs and other healthcare systems will further streamline workflows.
- Personalized Denial Management Solutions: The integration of AI will allow healthcare providers to move away from the one-size-fits-all approach to a more personalized denial management strategy.
Fight Claim Denials with Aidéo
Aidéo is a leading medical coding company that eliminates claim denials and optimizes your revenue cycle management. Our AI-powered platform, Gemini™, uses AI, ML, NLP, and advanced data analytics to generate codes for no-touch billing across numerous clinical specialties and settings.
Our coding technology processes up to 12 encounters per second, measuring throughput in seconds or minutes to empower healthcare providers with cutting-edge AI solutions that not only address the present coding challenges but also anticipate future ones.
Additionally, our exclusive licensing agreement with AAPC E/M coding calculator yields valuable insights such as the latest E/M codes, time-based guidelines, MDM definitions, shared or split service details, and more to ensure medical coders submit accurate claims each time.
Ready to experience the benefits of denial management with AI-powered medical coding? Book a demo today!
FAQs
Q1. What are the common reasons for claim denials?
Answer: Claim denials can occur for various reasons, including incorrect patient information, coding errors, lack of prior authorization, incomplete documentation, and non-covered services.
Q2. How can AI in medical coding help reduce claim denials?
Answer: AI in medical coding can reduce claim denials by enhancing coding accuracy (read our blog), automating repetitive tasks, providing predictive analytics, and more. AI algorithms provide real-time feedback to coders, can analyze coding patterns and historical data to identify potential errors, and also do real-time auditing to rectify coding issues promptly.
Q3. How can Aidéo help you fight claim denials?
Answer: We understand that denial rates pose a significant challenge for healthcare providers, leading to revenue loss and administrative burden. By partnering with Aidéo, you get automated coding and decision support systems across all specialties to help you mitigate denials and improve revenue.