Specialty claims become a priority as denials become a care quality issue

This year, specialty claims will become a frontline operational priority as hospitals realize reducing friction and denials is now a care-quality issue, not a finance issue. 

Moreover, AI-driven workflow intelligence becomes the only way hospitals can safely manage the rising complexity of cross-payer claim requirements, said Frank Forte, CEO of EnableComp, which develops an AI-powered revenue cycle management platform.

'Impossible to ignore'

"Specialty claims like Veterans Affairs, workers' comp, motor-vehicle accidents and out-of-state Medicaid are becoming increasingly difficult and impossible for hospitals to ignore," Forte explained. "What once seemed like isolated incidents is now a significant source of revenue loss.

"And this friction doesn't just affect the revenue cycle – it also affects patients," he continued. "These types of claims tend to have some of the highest error and denial rates in the industry. When mistakes happen, patients often face surprise bills, delayed appointments and uncertainty about their coverage, among other issues."

At the same time, denial rates are rising exponentially – some provider organization leaders are beginning to call it a "complexity crisis."

"Essentially, this means that reimbursement has become so unpredictable that it impacts many areas of a health system, including patient care," Forte noted. "These areas encompass staffing, service-line decisions and even how quickly patients can receive treatment. Specialty claims often serve as the first sign that a hospital's overall financial health is under strain.

"A similar pattern appears in complex clinical denials, including DRG downgrades, ED downgrades, medical necessity disputes and coordination-of-benefits issues," he continued. "These are no longer rare. They rely on perfect documentation and are constantly influenced by changing payer rules."

Far-reaching consequences

As they accumulate, the consequences extend well beyond finances – clinicians spend time defending care they have already provided, he added. Patients remain in coverage limbo, and the entire organization grinds to a halt due to administrative rework, he said.

"For years, hospitals considered both specialty claims and clinical denials as minor operational issues that small internal teams would 'handle,'" he explained. "However, these problems have grown too large to ignore. When claims bounce around for months or are never submitted, it's not just lost revenue. It undermines patients' trust in their hospital's ability to guide them through an already complicated system.

"What's becoming clearer is that administrative performance and clinical experience are closely linked," he continued. "For example, when a workers' compensation or VA claim remains unresolved for 180 days, that delay isn't just a number on a spreadsheet. It affects whether a patient gets follow-up care, whether a clinic can staff appropriately and whether the organization can invest in services people depend on."

Going into 2026, hospitals are gearing up to make the most complex corners of the revenue cycle real priorities, he predicted.

"And when they do, the benefits show up on both sides," he noted. "This means a firmer financial footing and a smoother, more predictable patient experience. Removing barriers in the most complex parts of the revenue cycle doesn't just clean up operations. It directly improves access to care.

"It also strengthens the relationship between patients and those who care for them," he added. "Ultimately, it helps hospitals stay on solid ground in a reimbursement environment that's changing faster than anyone would like."

AI workflow intelligence

Also in 2026, Forte said, AI-driven workflow intelligence will become the only way hospitals can safely manage the rising complexity of cross-payer claim requirements.

"AI-driven workflows and advanced analytics are becoming crucial as hospitals face escalating financial and operational pressures from workforce shortages, cybersecurity risks and rising reimbursement complexity," he said. "We have reached the point where manual processes, and even modern EHRs, can't keep up.

"What used to be a predictable workflow is now a moving target, and traditional systems weren't designed for this rapid pace of change," he continued. "Without technology capable of handling this complexity, organizations are essentially reacting after the damage is done."

AI can transform that dynamic entirely, he contended.

AI-automated workflows

"By applying AI in proven, practical ways to automate workflows – such as check-in, eligibility verification, prior authorization and coding support – staff can focus on the exceptions that truly require their expertise," Forte said. "For example, workflows that took 90 minutes to complete can now be finished in seconds.

"With its inherent application of data and advanced analytics, AI recognizes patterns that humans cannot see," he continued. "So, it can identify subtle underpayments, emerging denial risks, documentation weaknesses and payer behaviors that indicate trouble ahead."

Further, it has the potential to predict the likelihood of a denial before submission and automate parts of the appeals process that usually consume time and resources.

"Throughout, it enhances staff expertise by guiding teams to the most critical issues and providing the insights needed to address them quickly and accurately," he concluded.

Follow Bill's health IT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.

WATCH NOW: Grabbing the Chief AI Officer brass ring – and working with top brass