Podcast Summary: Optimizing Clinical Denials Management with AI
Podcast: Becker’s Healthcare Podcast
Episode Title: Optimizing Clinical Denials Management with AI
Date: September 5, 2025
Host: Lucas Voss (Becker’s Healthcare)
Guest: Jim Bonesack (Chief Strategy and Client Officer, Experian)
Episode Overview
In this insightful episode, Lucas Voss talks with Jim Bonesack, an experienced revenue cycle leader, about the pivotal role of artificial intelligence in optimizing clinical denials management. The conversation covers current challenges faced by providers, the transformative impact of AI technologies, and strategic approaches for healthcare organizations to stay competitive amidst growing payer complexity and administrative cost pressures.
Key Discussion Points & Insights
1. The Clinical Denials Landscape: Pre- and Post-AI
[01:31 – 05:09]
- Historic Imbalance:
- Traditionally, payers have broad visibility across many claims but lack clinical depth; providers have deep clinical data on individual claims but lack payers’ breadth.
- This imbalance leads to ongoing friction and growing numbers of clinical denials.
- Emergence of Complex Denials:
- Recent years have seen a significant increase in denials requiring detailed clinical appeals, especially for inpatient stays.
- Payers increasingly deny claims pending clinical validation, shifting from simple coding errors to nuanced medical necessity issues.
- Providers now face demands to extract, collate, and present justification from complex medical records, requiring skilled (and costly) talent like nurses and coders.
- AI’s Role:
- Payers are leveraging large language models to audit and automate denials, raising the bar for providers to respond efficiently and comprehensively.
Quote:
"These are, I disagree with you. It wasn’t medically necessary or wasn’t that complex. Write me a letter pulling clinical documentation and evidence and send it to me and prove it. ... That’s tough for providers. They don’t have a bunch of resources sitting around wanting to write letters."
— Jim Bonesack [03:07]
2. AI-Driven Optimization: Results and Metrics
[05:09 – 08:59]
-
Strategic Approach to Implementation:
- Experian adopted a phased approach—incrementally deploying AI tools for specific appeal tasks rather than full end-to-end automation.
- Focused on supplementing human effort, ensuring AI-produced appeals are as good or better than those written manually.
-
Impact Metrics:
- Automated Appeals Coverage: AI now covers almost 70% of clinical denial types for generating automated appeal letters.
- Speed and Efficiency: Reduced time from placement to appeal writing by 35% (removing about 40 days from the process).
- Quality: Overturn rates on appeals increased by ~25%, with AI surfacing more comprehensive evidence from medical records.
- Reduction in Appeal Volume: Fewer total appeals needed, as initial submissions are more robust (10-15% reduction in subsequent appeals).
Quote:
"We’ve lowered the days from our placement to appeal writing by 35%. So we’ve taken 40 days out of the process of getting an appeal out the door. ... The overturn rate going up beyond what a human can do is also super important."
— Jim Bonesack [06:35]
3. Strategic Advice for Healthcare Leaders
[09:00 – 13:04]
-
Challenges Beyond Technology:
- Increasing payer tactics (e.g., post-payment reviews, DRG downgrades) are intensifying the workload.
- Acknowledges some payer strategies as “dirty pool,” emphasizing the unfairness and complexity of current practices.
-
Not a Human-Scalable Problem:
- The demand for clinical staff to fight denials is unsustainable and often unfulfilling.
- Recruiting and retaining skilled workers for this task is increasingly challenging and costly.
-
Call to Action for Provider Organizations:
- AI and technology are necessary to respond to denials at scale—adding more staff is no longer viable.
- Providers should honestly assess their resources and consider:
- Licensing technology to empower internal teams
- Partnering for full-service solutions
- Determining the right blend of tech and people for their situation
Quote:
"It really is. It’s not only volume of denials, but it’s the particular type of denial and the response required to address it. ... I’m convinced ... it’s not a human scale problem. We can’t add more people and fix this problem. We have to respond in a technological way."
— Jim Bonesack [11:58]
4. Final Thoughts and the Future
[13:39 – 14:51]
- Define “AI” Clearly:
- There’s a lot of industry hype; leaders must understand what AI/ML means in practical terms and how it can be implemented.
- Closing Gaps:
- Payers are outpacing providers in AI adoption, requiring urgent action from provider organizations to close the gap.
- Multiple Paths:
- Organizations should evaluate different AI solutions; there’s no one-size-fits-all.
- The pace of change in healthcare administration is unprecedented, offering both challenge and opportunity.
Quote:
"Health care can’t afford to keep this pace. So we, we have to do it. How do we do it? In a thoughtful way. Multiple approaches. But we’re all getting towards the same thing. It’s tremendous. In my career I’ve never seen the pace of change this fast."
— Jim Bonesack [14:25]
Notable Quotes & Memorable Moments
-
On Administrative Complexity:
"Whereas we used to get lesser amounts of clinical denials ... Those are growing exponentially at this point, where the volume is just out of control."
— Jim Bonesack [02:27] -
On Provider Challenges:
"I don’t know many coders or nurses that say I went and got trained and certified ... so I could write letters back to the payer to argue something. ... That’s not a satisfying job."
— Jim Bonesack [12:17] -
Sports Metaphor on Appeals:
"Three shots on goal, but you got to stay on the ball, right?"
— Lucas Voss [14:51]
Timestamps for Important Segments
- 00:34 — Jim Bonesack’s career background and expertise
- 01:31 — Current and historical challenges in clinical denials
- 05:44 — Concrete examples of AI-driven outcomes
- 06:35 — Quantifiable impact of AI: speed, quality, and volume metrics
- 09:40 — Provider skepticism and strategic advice
- 11:58 — The necessity of a technology-driven solution
- 13:39 — Final thoughts on defining and implementing AI
- 14:25 — The unprecedented pace of industry change
Conclusion
This episode underscores the urgent need for healthcare providers to embrace AI and advanced technology solutions to manage spiraling clinical denials, reduce administrative burden, and optimize reimbursement. With practical metrics, candid commentary, and an honest assessment of industry dynamics, Jim Bonesack offers clear guidance for leaders seeking both immediate ROI and sustainable, long-term advantage.