By Subrahmanyam Mantha

For healthcare, artificial intelligence promises improved member experience, quality, and economic opportunity for health plans. How is AI delivering on the promise? According to McKinsey research, with technology including AI, payers could experience net savings of 13 to 25% in administrative costs and 5 to 11% in medical costs as well as 3 to 12% higher revenue.

There are significant opportunities all along the payer points of service. Payment integrity (PI), as a touchpoint central to claims adjudication, reimbursement, and value-based care delivery, is ideally suited to the enhanced accuracy, savings, and speed to pay. But it’s not technology in isolation that will solve for the complexities of this point of service.
Sagility recently conducted research on the topic of, “What payment integrity solution brings optimal benefits to your organization?” And, reliably, “Tech and Analytics” was chosen by 23% of our respondents. However it’s key to note that “Pre-Pay Audits” ranked highest at 44%, with Data Mining/Clinical Audits at 17% and Post-Pay Audits at 16%. This tells us that while emerging enablement like AI is a key factor—the focus remains on a combination of people, process, and technology, along the payment integrity value chain.

When it comes to delivering on the promise of AI, payment integrity optimization relies on a comprehensive expertise and set of people, process and technology solutions, for the right combination to accelerate outcomes.

People with healthcare domain expertise
The human impact should not be lost— AI gurus also need to be backed by expertise in complex healthcare payment integrity nuances, with current knowledge of ever-changing regulations and market factors. Specialized payment integrity and clinical resources can identify the efficiencies required to answer the most pressing business challenges. Experts can provide top-notch analytic tools and techniques that are combined with automation, machine learning, custom configuration and manual review and intervention to analyze the claims data. The right experts deliver a brain-bot combination, bringing the human ingenuity via skilled, experienced payment integrity specialists. Finally, the right payment integrity expertise requires knowledgeable resources across IT, PI and the special investigative unit (SIU) to maximize actionable findings.

Without human ingenuity for the critical thinking behind tech enablement, disruption like AI can go off course and create bigger issues for healthcare organizations. The right healthcare services partner will have pure-play healthcare domain expertise—in addition to the technologies to accelerate outcomes. Today’s PI team can’t rest on tech experts alone. The best team is one that is hybrid and multi-faceted, with claims examiners, certified coders, licensed nurses, physicians, and data analysts. This core team can accelerate adjudication and enhance and improve payment accuracy, ensuring effective claims operations that will reduce downstream efforts.

Artificial Intelligence Homepage