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What is claims analytics?

Anyone that works with healthcare claims can confidently report that so much of their time is spent gathering and organizing all the right information to analyze their claims data. 

In fact, healthcare claims analysis is 80% preparation and 20% analytics, research says, but “could be even more extreme due to the complex nature existent in healthcare data.”

As technology continues to improve, the disparity between preparation time and analytics time is shrinking and claims analytics is becoming a great tool to aid practices nationally. 

The term claims analytics is used to describe software that analyzes healthcare claims and cost data to increase revenue and decrease patient AR days. 

Claims analytics is often synonymously labeled as predictive analytics or predictive modeling though they aren’t the same. 

Predictive modeling refers to the use of machine learning and/or AI to predict patient outcomes and improve patient well-being. Claims analytics utilizes healthcare claims and payer contract management to assist healthcare billing experts in understanding revenue and AR issues. Data found through claims analytics can be useful in detecting and reworking denials and payment variance.  

Rivet’s claim analytics tool allows you to filter and segment your claims data to quickly identify trends and drill down to the specific claims driving them—all within a few clicks. You can easily review what’s happening in your practice and where you can increase revenue. 

Ok, so claims analytics might be nice, but when would you use claims analytics?


Example #1

You’ve identified an issue with a claim and you’re wondering if it’s happening with other claims.

With Rivet Claims Analytics, you can see both individual claims and big picture trends within seconds. There’s no need to open a spreadsheet, which is especially convenient for one of our customers that previously used 72 spreadsheets to manage his claim queries and workflows. 


Example #2

You want to know...

  • how many times you billed a certain CPT code with a specific diagnosis.
  • which CPT codes are the most prone to denials.
  • how many of a specific denial type you have, listed by payer. 

With Rivet, you can easily add or remove filters to get a completely new look at your data with a few clicks.


Many companies offer claims analytics, but the downsides to their products can be severe. For instance, the company Ability offers free or cheap tools that especially focus on Medicare claims, but then they continuously upsell. They are said to increase prices frequently and make contract cancellation difficult. Other companies offer outdated systems that are hard to use or cost an arm and a leg to continue using. 

Tonia Bateman, Business Office Director at New Mexico Oncology Hematology Consultants, said that before trying Rivet, her team used Experian. It was so complex, Bateman said, that she had one senior person champion their Experian efforts constantly. “It wasn’t user friendly and didn’t have a good support system,” she said.

"When we did a Rivet demo, I just fell in love with it,” Bateman continued. “I loved the analytics piece, the reporting, that it was so easy to use, that you could drill down different ways, and that it integrated with our practice management system. I knew this is what we had to do and it’s been a great investment for us.”

As mentioned previously, claims analytics software can get pricey, and alternatives can be appealing, especially when it’s included in your practice management (PM) system. But that may not be the best answer for you when Rivet integrates seamlessly with so many PM systems.

Allison Snow, Analytics & Implementation Manager at Florida Eye Specialists & Cataract Institute had a lot to say about her PM system’s claims analytics tool. “Our PM system has something like Rivet but not as forthcoming.” With Rivet, Snow said, “You can drill down into details, (reason for denials, preventable things), see where we are spending resources and prevent denials from even happening.”

Along with claims analytics, Rivet also offers many other features such as the following:

  • Net revenue reporting. Understand the state of your revenue and AR at a glance and dig deeper through criteria such as date range, payer and provider. You’ll be able to quickly prepare for upcoming meetings and check on financial status at any time, in no time. 
  • Adjudication history. Easily see the adjudication history of a claim and the details of every EOB related to a claim. All your claim information can be in one place, so you’re not having to track down documents for any questions you may have.
  • Denials reporting and detection. Get automated denial detection so you can quickly identify trends driving your denials. You can make decisions, confidently knowing that they make a huge impact on your future workload.

And that’s just the beginning.

Rivet also offers a patient estimates and eligibility checks tool, an underpayment detection and workflow tool and a denials workflow tool. 

For more information about the Rivet's modern product suite, schedule a Rivet demo.