Health care claims denials pose significant challenges for providers, draining resources, delaying payments, and affecting patient experiences. Common causes include incomplete documentation, coding errors, and eligibility issues. Though many denials are reversed, the rework process is costly and time-intensive. Denial rates have surged due to complex payer requirements and stringent claims reviews, threatening financial sustainability for health systems and physician practices. This situation can frustrate patients, leading to unexpected bills and care delays.
However, artificial intelligence (AI) is emerging as a viable solution to mitigate these challenges. AI-driven platforms can review clinical documentation, ensure correct coding, and verify prior authorization before claim submission. Predictive analytics identify high-risk claims, facilitating proactive interventions. Additionally, tools that automate appeal processes enhance overturn rates. With increasing recognition of AI’s benefits, these technologies aim to support rather than replace human decision-making, seamlessly integrating into workflows to enhance accuracy and rebuild trust in the claims process.
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