Key takeaways:
- As claims denial charges proceed to climb, strain is mounting on healthcare organizations to seek out new methods to scale back denials.
- Leveraging synthetic intelligence (AI) and automation-based instruments, like Experian Well being’s AI Advantage™ and Patient Access Curator™ options, is confirmed to decrease denial charges.
- More than half of survey respondents say they’d change present claims administration platforms if introduced with compelling ROI to make the change.
Claim denials are a well-documented problem for healthcare organizations. Denied claims take for much longer to pay out than first-time claims, in the event that they receives a commission in any respect. Every one means further hours of rework and follow-up, pulling in further sources as workers evaluation payer insurance policies and determine what went flawed. It’s time-consuming and dear. Past {dollars} and paperwork, denials have an effect on affected person care as uncertainty about funds results in delays in remedy or sudden out-of-pocket prices.
However how do healthcare leaders really feel in regards to the state of claims administration immediately? How are they tackling the executive burden? Is there any gentle on the finish of the denials tunnel? Experian Well being surveyed 250 healthcare revenue cycle leaders to seek out out.
The 2025 State of Claims report breaks down the survey findings, together with insights into how automation and AI know-how are getting used (or not!) to optimize the claims course of for denial prevention and improve income.
What’s the present denial charge for healthcare claims?
Well being claims are nonetheless caught in a cycle of denials, delays and knowledge errors. 41% of survey respondents mentioned that a minimum of one in ten claims is denied. That’s loads of rework and misplaced income that suppliers had been relying on.
In 2009, claims processing accounted for round $210 billion in “wasted” healthcare {dollars} within the US. A decade later, the invoice had climbed to $265 billion. Trade studies – together with Experian Well being’s State of Claims collection – repeatedly noticed an increase in denial charges.
At the moment, 54% of providers agree that declare denials are rising. And with this improve, suppliers consistently fear about who can pay – and when.
What are the most typical causes for healthcare declare denials?
In accordance with the State of Claim survey respondents, the highest three causes for denials are lacking or inaccurate knowledge, authorizations and inaccurate or incomplete affected person data. In brief? The issue is unhealthy knowledge.
26% say that 10% of denials end result from inaccurate or incomplete knowledge collected at affected person consumption. Given how a lot data must be processed and arranged to fill out a single declare, this isn’t stunning. From affected person data to altering payer guidelines, the sheer quantity of knowledge factors to be collected and collated creates too many alternatives for errors and omissions.
Different challenges, akin to coding errors, uncovered providers, eligibility checks, and staff shortages nonetheless play a job, however it’s clear that fixing the info drawback may make a significant dent within the denials drawback.
Might automation enhance declare denial statistics?
To assist break the denial spiral, extra healthcare suppliers are turning to claims management software. Leveraging know-how helps organizations resolve or forestall the snags that intrude with claims processing and billing workflows – enhance declare success charges. That mentioned, around half of providers nonetheless evaluation claims manually.
But, regardless of the confirmed advantages of built-in workflows and automation, the drive to implement new know-how appears to have misplaced momentum.
In 2025, 41% of survey respondents say they upgraded or changed their claims administration know-how within the final yr. Nevertheless, 56% say that their present claims know-how is adequate to handle income cycle calls for – far beneath the 77% in 2022.
Whereas some duties nonetheless genuinely require a human contact, workers time is usually wasted on repetitive, process-driven actions that might be higher dealt with via automation.
Listed below are just a few methods claims automation may also help improve claim denial statistics:
- Join your complete claims course of end-to-end: Utilizing an automatic, scalable claims administration system – like ClaimSource® – helps suppliers handle your complete claims cycle in a single utility. From importing claims information for sooner processing to robotically formatting and submitting claims to payers, it simplifies the claims modifying and submission course of to spice up productiveness.
- Submit extra correct claims: 68% of survey respondents say submitting clear claims is tougher than a yr in the past. There’s a robust case, then, for utilizing an automatic declare scrubbing instrument to scale back errors. Claim Scrubber evaluations pre-billed claims line by line so errors are caught and corrected earlier than being submitted to the payer, leading to fewer undercharges and denials and higher use of workers time.
- Enhance money circulate: Automating declare standing monitoring is one method to speed up claims processing and time to cost. Enhanced Claim Status eliminates guide follow-up so workers can course of pended, returned-to-provider, denied, or zero-pay transactions as shortly as attainable.
- Cut back denials: Denials Workflow Manager automates the denial course of to get rid of the necessity for guide evaluations. It helps workers establish denied claims that may be resubmitted and tracks the foundation causes of denials to establish traits and enhance efficiency. It additionally integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so workers can view declare and denial data on a single display screen.
Bettering declare denial statistics with AI
Whereas automation quickens the denials workflow by taking good care of knowledge entry, AI can study that knowledge and suggest subsequent steps.
Of the 14% of survey respondents who mentioned their group is at present utilizing AI, 69% say that AI options have boosted claims success charges, decreasing denials and/or rising the success of resubmissions.
Present ClaimSource customers can now degree up their complete claims administration system with AI Advantage, which interprets historic claims knowledge and payer habits to foretell and stop denials. The video beneath provides a useful walk-through of how AI Advantage’s two choices, Predict Denials and Denial Triage, may also help suppliers reply to the rising problem of denials.
Moreover, turnkey AI options, like Patient Access Curator (PAC), enable organizations to make sure claims are processed precisely from the beginning. Launched in 2025, PAC is a groundbreaking instrument that consolidates vital features like eligibility checks, MBI, demographics and discovery into one seamless answer – maximizing clear claims and minimizing denials, appeals and resubmissions.
Discover how Experian Well being is reshaping the way in which well being programs handle Coordination of Advantages. Find out how automation and AI are eliminating guide errors, decreasing denials and unlocking tens of millions in recoverable income.
Can AI break the claims denial spiral?
Expertise is important to enhancing claims administration processes, and 59% of survey respondents say they plan to spend money on claims administration know-how within the subsequent six months. Leveraging AI for claims management may break the cycle of denials, however is healthcare able to belief it?
Regardless of a stable understanding of AI’s potential, survey findings recommend many healthcare organizations nonetheless have issues. According to the data, prime worries embrace its accuracy, HIPAA compliance, the necessity for employees coaching on new know-how, and AI’s understanding of payer-specific guidelines.
Nevertheless, as declare denials proceed to rise, organizations that make the leap to undertake technology-based options that leverage automation and AI may forestall extra denials and degree the taking part in discipline with payers.
Obtain Experian Health’s 2025 State of Claims report for an inside have a look at the most recent declare denial statistics and business views on claims and denials administration.
