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Preventing and appealing clinical denials with analytics, automation, and AI

U.S. hospitals lose $262 billion due to denied claims each year, representing 10% of the total claims paid. Unraveling the root cause of denials costs an average of $118 for each claim. Applying modern technology — such as analytics, automation, and artificial intelligence (AI) — can help to increase the number of clinical denials investigated, boost appeal effectiveness, and unearth root cause.

A COVID-19 update from our company’s consulting physician

Throughout 2020 and as we plan for 2021, HGS has trusted the professional insights of Dr. Virginia Gurley, whose steady and reliable point of view has provided us with a sound perspective regarding the pandemic. Her end-of-year statement offers guidance as well as words of encouragement for the months ahead. “COVID-19 has spread by leaps […]

Member experience: Never a better time for digital enablement

Health plans are all too familiar with the challenges of member experience—that perfect storm of call/processing volume surge, staffing challenges, and critical moment-of-truth engagement pressures. And the stakes are even higher for 2021, according to JD Power research.  The organization’s fourth annual study found that member satisfaction averages dropped from 712 on a 1,000-point scale […]

Precision utilization management: Meeting patients where they are

Providers view prior authorization as a manual, burdensome, and laborious process, mostly because of process missteps such as lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. According to a recent American Medical Association survey, handling the surging prior authorization requests translates into a “high” or “extremely high” burden […]

Bridging provider-payer gaps with today’s technology

Across the world, today’s healthcare organizations are sharing one critical challenge: the rising costs associated with improvement in quality care. The underlying mandate is that all stakeholders must keep a sharp focus on making healthcare more effective, efficient, and affordable. To meet this new demand, both payers and providers have made adjustments to service delivery—and […]

For a more holistic SDoH picture, look at social determinants of mental health

By Daniel A. Schulte, Senior Vice President, Provider Operations, HGS Healthcare As members of the broader healthcare community, we have been reviewing the many facets of the general healthcare delivery environment: from the old-school “diagnosis and treatment plan” strategy to understanding more about the patient’s real-world constraints on the path to wellness. In addition to […]

20/20 vision: 9 trends at the heart of tomorrow’s healthcare

From an in-control consumer to digital experience and telemedicine, healthcare delivery continues to stretch the limits of what we thought possible. As health plans and health systems increasingly turn to outsourcing partners to compete and thrive in this ever-changing market, we’re here with HGS’s on-the-ground assessment of Healthcare 2020. And, at the core of the […]

Medical credentialing: A safeguard worthy of significant support

By Priyankar Bhattacharya, HGS Senior Manager, Provider Network Operations Today’s healthcare payer and provider organizations are increasingly focusing efforts on physician credentialing for real outcomes such as significant cost savings, turnaround time enhancement, accuracy improvement, and reduced rework. This service area originated in the 1960s, with the Darling v. Charleston Community Memorial Hospital case,  which […]

Next frontier in healthcare claims automation

By Manjunath, Practice Lead, Claims Adjudication, HGS Claims optimization continues to provide health insurers a key area of opportunity to reduce consistently high loss ratios.  In fact, the U.S. healthcare industry has a significant opportunity to deploy claims automation to save $11.1 billion annually, according to new data released in the fifth annual CAQH Index. […]

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