The Executive Suite: AI agents: The solution to common pain points in health care administration

When patients visit family clinics to address health issues, they expect quality care, and an easy billing process. However, these interactions can be stressful, especially when issues like incorrect patient bills arise. Such situations can be particularly challenging for individuals who are primarily focused on meeting their families' basic needs and may not have the bandwidth to deal with unexpected financial statements.

The frustrations experienced in healthcare settings, including billing discrepancies, service levels, wait times, and other aspects of the patient journey, often stemming from underlying administrative challenges. Underneath their cool patient-centered focus, well-meaning healthcare providers are struggling with admin issues. A key contributing factor is the ongoing struggle to maintain an adequate workforce in the back office, which is essential for the smooth functioning of healthcare practices. This challenge is exacerbated by the current labor market dynamics, as highlighted in reports on the shrinking talent pool.

At the same time, their claims denial rates continue to rise as insurance providers frequently alter their contracts, making reimbursement increasingly challenging. Healthcare providers lacking the administrative resources to meticulously review each claim and service find securing reimbursement from insurance companies increasingly tricky.

These three areas are particularly problematic, and addressing them is critical. The solution? A new introduction to the market, AI Agents, offer a promising pathway for family clinics and other healthcare providers to mitigate claims denials, enhance reimbursement rates, improve patient experiences, and refocus their efforts on core healthcare services. Healthcare back-office AI Agents are capable of various roles including:

Patient eligibility verification

Family clinics often handle a high volume of patients, including both scheduled appointments and walk-ins. Each patient comes with a unique reimbursement plan, making it difficult to determine their eligibility and available healthcare services quickly and on a large scale.

Reimbursement eligibility is nuanced and complex. It includes various factors such as an evaluation of the services covered by health insurance companies, the levels of reimbursement, and unique criteria that can qualify or disqualify a patient's services for reimbursement. This landscape is constantly changing as patients frequently switch insurance providers or plans, and their basic profile information, such as home address, may also change over time.

This complexity makes it difficult for family clinics to know what will be reimbursed, which leads to an unnecessary amount of claim denials without proper patient eligibility verification.

Thankfully implementing an AI Agent-powered eligibility verification function in their revenue cycle departments can help healthcare providers like family clinics. The AI Agent can sort through heaps of information quickly to verify each appointment and walk-in, ensuring that the services provided are eligible for reimbursement, and enabling them to inform the patients immediately if not, leading to improved patient satisfaction.

Claims processing

Healthcare providers, such as family clinics must ensure that their claims are highly accurate for acceptance by clearinghouses and insurance providers. Due to the complex nature of claims, there are many opportunities for a claim to be blocked or denied.

Mistakes leading to claim denials often occur when Revenue Cycle Management (RCM) teams are overworked, leading to fatigue from handling repetitive processes. This results in additional time spent in claims processing as healthcare providers must spend extra time investigating and resubmitting claims. Some family clinics try to address this compounding work by hiring more staff. However, this approach often leads to a cycle of issues due to difficulties in hiring and retaining RCM staff, which result in turnover rates three to 10 times the industry standard.

Family clinics that employ AI Agents to ensure all information in their claims is correct and aligns with insurance companies’ expectations achieve extremely high collection rates. For providers who are comfortable continually hiring, training, retaining, and investing in more RCM staff, hiring more people is an option. Alternatively, they can configure an AI Agent once and benefit from 100% accuracy and infinite scalability.

Payment posting

Family clinics’ administrative challenges often extend to payment posting. Each patient’s insurance plan can vary significantly, making it challenging to manage and apply payments correctly, especially if a claim is denied or requires adjustments or necessitates additional follow-up and corrections. If a healthcare provider lacks the capacity to post payments accurately and promptly, it’s difficult to fully understand the financial health of its operation.

This also negatively affects the patient experience. An inaccurate ledger at a family clinic might lead to sending out incorrect bills or bills that shouldn’t be sent at all, leaving the patients frustrated and confused.

With AI agents, family clinics can ensure high-quality and timely payment posting, leading to a smoother back-office operation and an improved patient experience.

The bottom line

The combination of staffing shortages and reimbursement challenges presents significant hurdles for family clinics, especially amid aging population and growing healthcare demand.

Fortunately, integrating AI Agents throughout their operations empowers family clinics to optimize profitability, alleviate the perpetual cycle of hiring and training, and unlock operational excellence. This transformative approach enhances business outcomes and improves patient experiences, marking a pivotal step forward in healthcare delivery.