AI Denials Management
AI Denials Management involves the identification, analysis, and resolution of denied claims to ensure that providers receive reimbursement for services rendered. Products in this category perform functions including:
Recognizing claims that have been denied by the payer. This can be due to various reasons such as coding errors, incomplete information, or issues with patient eligibility.
Investigating or understanding the reasons for denial. This often involves using AI to review claim details, patient records, and communications with the payer.
Making necessary corrections to the denied claims and resubmitting them for approval. This might involve updating coding, providing additional documentation, or correcting patient information.
Given the need to interpret claims responses and automate them in many cases, there are strong connections between this category and products in Revenue Cycle Automation. Additionally, given that the goal of denial management is ultimately to reduce denials, many products in End-to-End Revenue Cycle Management also offer denials management workflows.
Product Usage: Candid is mainly used for post-visit claims adjudication, including claim submission, payment posting, denial management, accounts receivable, and reporting.
Strengths: The product offers a clear user interface, sufficient denial management functionality, responsive customer service and is more cost-effective compared to competitors.
Weaknesses: The product lacks the ability to bulk edit claims and some configuration options are not available to end users but must be done by their engineering team.
Overall Judgment: Despite minor areas for improvement, the product is a valuable, cost-effective solution to revenue cycle management, with excellent customer service and a straightforward user interface.
Product Usage: The product is used for back-end revenue cycle processes, from claim submission to payer and patient payment reconciliation.
Strengths: The product is flexible, accepts APIs, and works with a variety of claim formats.
Weaknesses: The product is a startup, meaning they are still building and developing certain features that established products already have.
Overall Judgment: The reviewer deemed their choice of Candid Health to be the right one as it provides flexibility and partnership that other mature products might not offer.
Product Usage: Candid Health is used to submit claims, handle EFT/ERA and EDI enrollments, perform preliminary checks on claims, and manage the claims process through an integrated workflow.
Strengths: Candid Health’s key strengths include a highly responsive team, a tech-focused approach, and a flexible rules engine.
Weaknesses: Ambiguity in service scope was a challenge initially which led to some confusion about responsibilities, the CSV export feature has been less reliable, and larger-scale operations may want to bring certain services in-house to handle higher complexity.
Overall Judgment: Candid Health comes highly recommended for its high-quality sales process, support, and account management, with particularly positive remarks on its ability to improve workflows and its desire to grow with customer base.
Product Usage: The product has been used for about a year and a half for revenue cycle management and it is adapted for scaling up operations, including new features like remote patient monitoring-based billing.
Strengths: Its expertise, understanding of venture-backed companies, scalability, and tech focus made it stand out from the competition; it also provides proactive services and handles issues effectively, even offering support for troubleshooting.
Weaknesses: The product had minor issues which were promptly addressed with transparency; there were also some gaps in functionality which, though identified and prioritized by the company, led to delays in delivery.
Overall Judgment: The reviewer has had a positive experience with the product and its performance, communication, and support from the vendors, considering it to be one of the best vendors in delivering value from their product.