AI for Predicting and Preventing Claim Denials

Nearly three-quarters of providers have reported an unprecedented rise in claim denials over the last 5 years.

Claims denials are more than a financial burden - they’re a silent disruptor rippling through the healthcare ecosystem. From draining resources to hindering efficiency and compromising patient care, their impact is widespread. Between 2021 and 2023, denied claims surged from 8% to 11%, leaving providers to grapple with the fallout of over 110,000 unpaid claims.

Traditional approaches to managing these denials rely on reactive, labor-intensive processes - methods that not only result in millions in lost revenue but also exacerbate physician burnout, diverting focus from patient care.

What’s driving this alarming trend? The rapid adoption of AI-driven systems by insurers. While efficient for payers, these models generate denials at unprecedented rates, creating an uphill battle for providers. The consequences are stark: increased administrative workloads, delayed reimbursements, and heightened strain on already-stretched resources. 

The message is clear: providers must move from reactive to proactive strategies. By leveraging data-driven solutions, providers can prevent revenue loss, optimize workflows, and deliver high-quality care. 

In this AI-driven arms race, Citrus stands as a trusted ally. Our solutions are designed to assist providers in navigating these complexities, mitigating risks, and turning challenges into opportunities for success.

The Current Landscape 

Nearly 15% of claims submitted to private payers are initially denied, including those pre-approved through prior authorization. Denials are widespread for high-cost treatments, with the average denial exceeding $14,000 in charges. Medicare and Medicaid claims fare slightly better, with denial rates around 12%. While more than half of private payer denials (54%) are eventually overturned, this often requires costly and time-consuming provider appeals - delaying care and straining resources, underscoring the need for systemic reform. 

On average, a provider spends $43.80 to appeal each denied claim.

This statistic notably excludes the cost of clinical labor, which adds an estimated $13.29 per claim for general inpatient stays and $51.20 for inpatient surgeries, further increasing the overall adjudication burden. 

On average, providers had to complete three rounds of reviews with insurers, with each cycle lasting 45 to 60 days. These delays left 14% of all health system claims overdue for remittance, preventing providers from recovering costs for up to 6 months after rendering services. 

While provider systems experienced a 17% year-over-year drop in average days of cash on hand, insurers saw a 25% increase.

Revolutionizing Claims Management with Citrus

At Citrus, we empower providers and patients to harness the power of AI in combatting claim denials - both predictively and prescriptively. Our platform, Citrus Provider Pulse, analyzes billions of medical and pharmacy claims to uncover key trends and identify the root causes of payer denials. By providing actionable insights, Citrus helps care teams anticipate rejections, refine strategies, and stay ahead of the ever-evolving reimbursement trends. 

Prescriptively, our platform automates essential tasks to boost efficiency and throughput. For instance, users can quickly generate comprehensive appeal letters, streamlining the process to ensure timely, accurate responses to denials. 

Our provider partners often said, “We have no way of knowing if our denial follow-ups are adding value.”

• Optimizing Eligibility Verification: Citrus Provider Pulse seamlessly integrates with EHR systems, automatically extracting patient data to ensure up-to-date insurance information. Providers reduced “service not covered” denials by 11% without needing to hire additional staff. 

• Predictive Support: By analyzing payer adjudication patterns, we uncover undocumented rules that can trigger denials, helping providers prevent issues before they arise. For example, we partnered with a care team in Portland, Maine, to analyze historical claims data for patients with Postural orthostatic tachycardia syndrome (POTS). By predicting denial risks based on factors like diagnosis, treatment, and insurance, the team reduced denials by 5% in just 2 months. 

• Streamlining Appeals: Citrus automatically generates appeal letters tailored to specific denial reasons, saving time and improving success rates. Citrus Provider Pulse also identifies denials with the highest reimbursement potential. As a result, providers increased denial overturns by 7% and reduced time spent on appeals from 20 minutes to just 5 minutes.

Ready to take control of claim denials and unlock your organization's full potential? Let Citrus show you how - reach out today!