Financial and Revenue Intelligence: How Claims Data Improves Payer Mix, Coding Accuracy & MIPS Scores

Today’s financial climate continues to create pressures within health systems to do more with less. Less staff, less time, less reimbursement, and less margin for error. As pressures grow around the front and back end of a practice’s operations, one differentiating factor is becoming the top strategic asset for high-performing practices.

Claims Intelligence

Through the application of advanced analytics and AI modeling, practices are empowered with claims intelligence and the ability to understand, well before revenue reaches billing, a practice’s visibility and insight relative to a payer's behaviors, coding, denial risks, and revenue cycle performance opportunities.

Enable Healthcare’s ecosystem, with RevQ AI Modeling, the EHI EHR, Aria One, and a practice’s ability to transform raw claims data, is a MIPS scoring machine, financial roadmap creator, and enhanced payer mix and billing optimization tool.

Here’s how practices can leverage claims intelligence to improve financial outcomes and economic stability over time.

1. Optimize Payer Mix With Data-Driven Insights 

Most practices assume they understand which payers are the most/least profitable. Claims intelligence often reveals a different and more accurate story.

A strong payer mix begins with understanding: 

• Reimbursement variation by plan

(Some plans consistently reimburse contracted rates below.)

·       Denial frequency and reasons

·       Turnaround times per payer

·       Administrative burden ratios

·       Utilization trends for high-need populations 

With RevQ AI Modeling, practices can benchmark claims outcomes and claims performance across EDI 837/835, EOB posting, and payer behaviors to enable providers to:

·       Identify payers driving revenue leakage

·       Negotiate smarter contracts

·       Shift scheduling bandwidth toward higher-yield plans

·       Reduce participation in underpaying or high-denial networks 

A more robust payer mix is NOT just about seeing more patients. It is about seeing the right patients, more strategically.

 2. Improve Coding Accuracy & Reduce Denials at the Source 

Denial spikes and revenue performance are both affected by coding accuracy, and coding accuracy is so important because of its impact on revenue performance.

Knowing their coding patterns by clinician, service line, and payer, and how claims intelligence assists providers.

RevQ AI Modeling benchmarks coding behavior by: 

·       LCD and NCD guidelines

·       CPT/HCPCS frequency

·       ICD alignment

·       Age/gender validation rules

·       Modifier usage

·       Deleted or outdated CPT codes

·       HMO and plan-specific requirements 

This goes much deeper than simply "billing cleanup." This allows practices to mitigate submission of claims and thus, learn how to avoid problems, including:

·       Avoidable denials

·       Resubmission cycles

·       A/R days

·       Compliance risks 

Real-time ICD coding, documentation prompts, and payer rule check compliance are built into Enable Healthcare's EHR and Aria One AI, which further simplifies these workflows.

3. Boost MIPS Scores With Predictive Performance Intelligence 

Relatively speaking, practices can no longer "hope for the best" when it comes to MIPS scoring, as it has much more substantial ramifications.

·       CMS incentive payments

·       Quality program bonuses

·       Reputation and star ratings

·       Long-term financial positioning 

With claims intelligence, practices can learn about issues concerning:

Gaps in MIPS quality measures 

·       Missing documentation

·       Under-reported codes

·       Uncaptured chronic conditions

·       Poorly documented encounters 

High-impact improvement areas 

·       Outcome metrics tied to CCM and RPM

·       Transitional care gaps

·       Preventive care utilization

·       Visit frequency and care coordination 

The data can also highlight best EHI workflows that are missing opportunities, particularly CCM, RPM, and APCM programs.

With Enable Healthcare's integrated MIPS monitoring tools, practices receive:

·       Real-time scoring visibility

·       Automated alerts for at-risk measures

·       Coding recommendations tied to quality metrics

·       AI-driven suggestions to improve category performance 

This results in a positive impact on outcomes and more CMS incentive payments. Documentation quality also improves.

4. Build a Strong, Proactive Revenue Cycle Ecosystem 

Analyzing the claims is about much more than just the financial side of things; it is also about anticipating and mitigating challenges.

With EHI’s financial intelligence stack, practices gain: 

·       Predictive denial modeling

·       Provider performance comparisons

·       Payer contract analysis

·       Patient responsibility forecasting

·       Revenue leakage dashboards

·       Referral tracking by payer profitability 

Financial teams can now work proactively instead of reactively as a result of this shift in the revenue cycle to proactive.

·       Correct documentation in real time

·       Target high-risk claims before submission

·       Understand payer-specific coding trends

·       Address persistent revenue leaks

·       Improve clean-claim rates and cash flow 

Elimination of guesswork is being replaced with clear, actionable insights.

5. Why Enable Healthcare Leads the Future of Claims Intelligence 

Enable Healthcare’s Ecosystem focuses on one primary mission: using intelligent data to aid practices in improving their financial, clinical, and operational performance.

EHI’s platform advantage includes: 

·       RevQ AI Modeling for deep claims analytics

·       EHI EHR for integrated coding, compliance, and documentation workflows

·       Aria One for real-time AI insights

·       Full-service RCM options if practices need extra support

·       CCM/RPM/APCM tools to maximize quality measure outcomes 

This is a claim's intelligence not only to analyze data but to empower everyday business decision-making.

Conclusion: Data is the New Financial Strategy 

Every practice has claims data.

However, only the best of the best practices utilize that data to create strategies, streamline operations, and anticipate the needs of the payers.

Enable Healthcare and RevQ AI Modeling, for the first time, guides providers down a clear and actionable path toward:

·       Improve payer mix

·       Strengthen coding accuracy

·       Boost MIPS scores

·       Reduce denials

·       Increase predictable revenue

·       Build long-term financial resilience 

Your financial intelligence is already in your data. EHI helps unlock it.