Transform audits with automated, targeted evidence collection
Validating the accuracy of claims is a cornerstone of payment integrity. Auditors must determine whether a treatment, procedure, or diagnosis is justified by closely examining medical records, clinical documentation, and the care provided by physicians.
These records can often span hundreds of pages, making the process not only highly labor-intensive but also time-consuming and prone to inconsistencies. Traditional approaches require auditors to manually comb through vast amounts of unstructured data, slowing down the claims validation process and increasing the risk of errors.
Key benefits:
- Automated evidence collection: AI agents identify and retrieve only the clinically relevant portions of medical records, reducing manual effort and ensuring faster, more consistent claim validations.
- Structured insights from unstructured data: By converting unstructured clinical documentation into structured, actionable insights, AI creates a repeatable workflow that minimizes errors and accelerates decision-making.
- Enhanced efficiency: AI reduces false positives, limits redundant documentation requests, and allows auditors to focus on high-value analysis, improving operational efficiency and scaling to meet growing claims volume.
Why it matters
As claims volume and complexity grow, traditional audit methods fall short. Agentic AI enables healthcare organizations to work smarter, scale faster, and ensure more accurate, timely, and fair audits. By automating repetitive tasks, AI empowers auditors to focus on critical clinical judgment, protecting revenue and strengthening payment integrity.
Seek expertise to implement agentic AI
Working with a trusted partner like EXL can accelerate the adoption and effectiveness of agentic AI in healthcare audits. EXL combines advanced technologies like AI and machine learning with deep industry expertise to deliver enhanced customer experiences and desired business outcomes. This integrated approach enables agile decision-making through relevant customer data points and actionable insights.