Transforming Payment Integrity with Artificial Intelligence
Artificial Intelligence (AI) is revolutionizing every sector, and healthcare is no exception. From early detection platforms to optimizing clinical workflows, and lately with the promise of Generative AI (GenAI) like ChatGPT, AI is advancing rapidly. While there is a growing list of ways health plans can leverage AI to decrease costs and increase quality, payment integrity and especially claims auditing is at the top.
Payer and Payment Integrity Challenges
At a macro level, payers are facing enormous challenges today—from surging medical costs, inflation, labor challenges, competitive pressures, and increasingly difficult network contract negotiations. Now more than ever, health plans need to optimize their cost models while improving the quality of their operations—a task well suited for AI and smart automation.
And as payment integrity teams are focused on detecting, correcting, and preventing payment inaccuracies across prospective (before payment) and retrospective (after payment) arenas, their work is mired in tedious administrative work which stifles performance and erodes margin. So where, and how, can AI help payment integrity teams?
AI in Payment Integrity
Whether a health plan chooses to leverage external vendors, internal audit teams, or a hybrid of both, there are several challenges that AI is well-positioned to address:
Audit Workflows
Streamlining processes in Diagnosis-Related Groups (DRG), Inpatient Bill Review (IBR), Quality & Compliance and High Dollar Claim Reviews
Coordination of Benefits (COB)
Verifying lead information, applying primacy logic, and analyzing claims for recovery—a process ripe for smart automation
Payment Integrity Performance Management
Understand audit and vendor performance at every level, detect trends, optimize performance, identify cost avoidance opportunities, and streamline administrative workflows that improve yield and conversion rates
Benefits of AI in Payment Integrity
Optimizing Pre-Payment Models: The industry is shifting from post-payment recovery to pre-payment cost avoidance models. AI-driven pre-payment models can prevent 100% of false claims costs, compared to recovering just 30% in post-payment models. While adoption has been cautious, AI’s agility and accuracy make pre-payment models more feasible. A balanced approach using both pre- and post-payment models is ideal.
Optimizing Vendor Stacks: AI enables real-time performance measurement, allowing payers to compare costs, quality, and findings across vendors—optimizing teams and the right resources.
Audit Selection: Machine learning and predictive analytics score claims, automate safe processes, and review high-impact cases. AI focuses resources on high-ROI activities, ensuring maximum efficiency.
Improving Hit Rates: AI reduces false positives and improves hit rates, minimizing provider abrasion and enhancing efficiency by targeting the right opportunities for scrutiny and overpayment recovery.
Increasing Throughput: AI automates administrative tasks and shrinks turnaround times, increasing the number of audits per cycle, decreases cycle times, and boosts overall production.
Machine-Grade Precision and Accuracy: AI doesn’t get tired and will review each claim and clinical chart with the same objective rigor, ensuring precision and accuracy without the risk of human error or fatigue.
Future of Payment Integrity with AI
AI integration promises a robust future for payment integrity. As the industry evolves with new technologies and payment models, AI will be pivotal in ensuring accurate claims adjudication and payments. AI-driven systems will streamline processes, reduce errors, and boost efficiency—transforming the PI industry and allowing health plans to benefit from maximum savings, minimum costs, and improved operational quality—a win for health plans, providers, and members.
Conclusion
AI is a game-changer for payment integrity in healthcare. By leveraging AI, payers can shift beyond just ‘doing more with less’ and truly level-up by empowering their teams to ‘do more of the right work with less’, achieving greater efficiency and accuracy. Explore the full potential of AI in payment integrity by contacting our team today and accelerating your journey with a proven platform.
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