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E-Newsletter • September 2026 |
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Editor's E-Note
Claims denials are costly, and they’re becoming more common. Payers are using AI tools to review and audit claims, and the result has been a noticeable uptick in denials.
A claim may be denied for any number of reasons, from incomplete coding and medical necessity gaps to missing prior authorizations and coordination-of-benefits errors. Inconsistent coding patterns can also cause a claim to be flagged. Considering that it can take months to find out about a denial or audit—at which time the care episode is likely forgotten—it’s important for health care providers to minimize the number of denials they receive. |
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One way that providers can reduce denials is to train AI algorithms and on the same data that payers are using to deny claims. This month, we’re looking at how AI and predictive analytics can put providers on a more-even playing field with payers and how these tools can, and should, be implemented.
In addition to reading our e-newsletter, be sure to visit For The Record’s website at www.fortherecordmag.com. We welcome your feedback at edit@gvpub.com. Follow For The Record on Facebook and X, formerly known as Twitter, too.
— Dave Yeager, editor |
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Health Care’s Quest for a Clean Claim
By Selena Chavis
Experts weigh in on the power of AI and predictive analytics to improve denials.
Revenue cycle professionals have prioritized claims accuracy and compliance as a process improvement priority for decades. Many agree that while the challenges associated with submitting clean claims haven’t changed much, they have certainly gotten more expensive.
According to Raja Yogeshwarar, executive vice president of growth and strategy at ECLAT Health Solutions, denials resulting from documentation that doesn't fully support the billed code level, medical necessity gaps, missing prior authorizations, and coordination-of-benefits errors remain the usual suspects. The less obvious problem is inconsistent coding patterns across providers or departments that don't look like bad claims individually but eventually surface as a trend a payer algorithm flags.
"The problem is that, traditionally, health systems find out about them in the denial or the audit letter, months after the patient encounter, when the medical record is cold and the staff who documented it may not remember the details," Yogeshwarar says.
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The Sequoia Project Releases Guidance to Advance Automated Consent
The Sequoia Project recently released a resource that provides practical guidance and tools to help organizations implement automated, computable consent processes for sharing health information.
What Drives High AI Scribe Utilization Rates?
A well-designed enterprise rollout done in partnership with a vendor can accelerate the value of ambient AI scribe deployments, reports Healthcare IT News.
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| Have a coding or documentation question? Get an expert answer by sending an email to edit@gvpub.com. |
OpenEvidence Launches Education Platform Offering CE and MOC Credit
OpenEvidence, an AI-powered medical search and decision support platform, has launched a new education platform offering accredited, interprofessional continuing education (CE) and Maintenance of Certification (MOC) credits for NPI-verified physicians, nurse practitioners, and physician associates. Physicians can additionally earn MOC credit through select certifying boards. As AI-powered clinical tools become increasingly common, it is essential that accredited CE keeps pace with the evolving reality of practice. The OpenEvidence Education Platform is powered by the same underlying models that support OpenEvidence, adapted to create personalized, accredited learning experiences for clinicians.
Itiliti Health Advances Prior Authorization Automation
Itiliti Health is transforming the prior authorization process with smart, scalable solutions built specifically for health plans. Designed to reduce administrative burden, improve provider collaboration, and enhance compliance, Itiliti Health’s platform enables automation and real-time decision support. The solutions are used to digitize medical policies, eliminate unnecessary manual reviews, and comply with evolving CMS interoperability standards. As health plans and state Medicaid agencies work to meet the January 1, 2027, CMS-0057 compliance deadline, Itiliti Health’s solutions enable payers to achieve full compliance with electronic prior authorization requirements while reducing administrative burden and improving the provider and patient experience. |
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