Inside Healthcare’s AI Playbook for Claims Denials

Denials delay reimbursement, force staff into manual rework, and contribute to an administrative burden that costs the system billions of dollars each year.

What is changing now is where AI is being applied. Instead of focusing primarily on fixing denied claims after the fact, providers and payers are deploying AI earlier in the revenue cycle to prevent denials from happening in the first place.

AI Moves Upstream in the Revenue Cycle

Historically, denial management has been reactive. Claims were submitted, rejected by payers for eligibility, coding or documentation issues, and then routed back to billing teams for correction and resubmission. That approach is labor-intensive and slow, often requiring multiple touchpoints and follow-ups.

AI tools are now being used to intervene earlier. AI models can analyze historical claims data to identify patterns that correlate with denials, such as missing prior authorizations, inconsistent patient information or payer-specific rule changes, Experian said in a Jan. 14 company blog post. These insights allow systems to flag claims that are likely to be denied before submission, giving staff an opportunity to correct issues proactively.

AI-driven automation can also streamline eligibility verification and benefits checks, which remain a source of denials, the post said. Automating those steps reduces reliance on manual lookups and phone calls, while improving accuracy in determining coverage details and patient responsibility. The result is fewer preventable denials tied to eligibility errors and incomplete information.

This upstream focus reflects a broader change in revenue cycle strategy. Rather than treating denials as an inevitable cost of doing business, providers are using AI to reshape workflows so that cleaner claims reach payers the first time.

Adoption Accelerates as Denial Pressure Grows

Most healthcare leaders view AI as a critical lever for reducing claims denials, particularly as payer rules become more complex and staffing shortages persist, according to a survey cited by the American Journal of Managed Care. Respondents pointed to automation, predictive analytics and real-time validation as areas where AI could have the greatest impact.

The urgency is tied to scale. Out of the $3 trillion in total claims submitted by healthcare organizations yearly, roughly $262 billion are denied, translating to an average of nearly $5 million in denials per provider annually, Health Catalyst reported. Reducing denial rates by a few percentage points can free up cash flow for large hospital systems, while also cutting the cost of rework and appeals.

AI tools are increasingly being integrated directly into electronic health records and revenue cycle platforms, allowing providers to embed denial prevention into everyday workflows, Healthcare Business Today reported. Use cases include real-time prompts for missing documentation, automated coding checks, and payer-specific rules engines that update as policies change.

Some early deployments are already producing measurable results. Minneapolis-based hospital system Allina Health said in October that an AI system developed by UnitedHealth Group helped reduce claims denials by identifying issues earlier in the submission process. The system analyzes claims data to surface anomalies and potential errors, enabling staff to correct them before they reach payers.

The reported outcome was a reduction in denial rates and faster reimbursement timelines, easing pressure on billing teams and cash flow. While results vary by organization and payer mix, these early case studies are reinforcing the value of shifting AI upstream.

As AI tools mature, vendors and providers are focusing on explainability and compliance, ensuring that automated decisions can be understood and audited. That focus is particularly important in healthcare, where regulatory scrutiny and payer disputes remain high.

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