Harnessing AI to decode unstructured data: A new era in payment integrity
Healthcare payers face mounting financial pressures as medical costs and administrative expenses rise, pushing medical loss ratios beyond 90%. Traditional payment integrity processes are slow, manual, and fragmented, leaving payers struggling to reduce improper payments and control costs. Enter AI and generative AI — game-changing technologies that transform how payment integrity teams discover, analyze, and operationalize rules.
The challenge of traditional payment integrity enhancements
Payment integrity ensures claims are paid correctly by preventing, detecting, and correcting improper payments. However, the process is often hindered by:
- Consistently evolving reimbursement policies, provider contracts, coding rules, and clinical guidelines that dictate how a claim is adjudicated and priced
- Time consuming manual research through unstructured documents searching for areas of potential risk
- Complex communication between SMEs and technical teams to convert findings into rules and protective coverage
- Slow workflows that delay results and waste resources on concepts that do not result in savings
Accelerating payment integrity innovation with AI and generative AI
AI revolutionizes payment integrity by automating discovery, accelerating insights, and driving results. Key benefits include:
- AI-assisted rule creation: Automatically extract key risk concepts and draft initial rule logic
- Democratized rule modification: Non-technical users can refine rules with conversational commands with AI tools automatically translating natural language into underlying query logic
- Smart prioritization: Focus on high-impact opportunities with predictive financial insights
- Improved collaboration: Guided workflows streamline and accelerate reviews and validate logic before deployment while preserving expert oversight
- Faster results: Reduce development timelines by up to 80%
The impact
By combining AI with human expertise, healthcare payers can:
- Accelerate speed to value
- Maximize ROI with strategic prioritization
- Enhance collaboration and transparency
Looking ahead
AI isn't just a tool - it's a strategic partner in payment integrity, enhancing human expertise by simplifying complex workflows, speeding discovery, and delivering measurable outcomes. Organizations that embrace AI-human collaboration will uncover hidden risks, improve margins, and maintain a competitive edge. Together, experts and AI can create payment integrity programs that are faster, smarter, and more sustainable.
Discover how AI can transform your payment integrity program. Download the white paper to unlock the data advantage today.