The advanced technology can transform the healthcare industry – including delivering significant savings opportunities to healthcare payers.
Generative AI, with its sophisticated large language models (LLM) and ability to generate content and predict patterns, is poised to revolutionize healthcare, an industry held back by slow technology adoption, operational inefficiencies and growing worker burnout. This transformation will redefine healthcare cost containment and dramatically reshape claim payments – giving healthcare cost containment teams a leg up in ensuring accurate payment integrity and identifying and stopping the waste, abuse, and fraud that plagues the industry today.
The positive impact of “Gen AI” will be far-reaching. Its algorithms, which boast self-learning and self-correcting capabilities, will help free healthcare organizations from time-consuming, complex tasks and allow them to focus on higher-value areas. Payment integrity operations can achieve significant efficiencies and propel their teams toward a zero-touch approach.
America’s Healthcare System: In Dire Need of Transformation
Recent data from the Peterson-KFF Health System Tracker shows a steady rise in U.S. healthcare costs correlating with a rise in hospital stays, which has led to an increase in inpatient and facility claims processing. In fact, the number of such claims, along with the cost of hospital and inpatient care, has grown in the last decade, with an estimated 589 million inpatient and facility claims processed in the United States in 2020, according to the Centers for Medicare & Medicaid Services (CMS). Of these claims, 385 million were for inpatient hospital stays, and 204 million were for other facility stays such as skilled nursing facilities, rehabilitation hospitals, and long-term acute care hospitals.
This surge in highly complex claims and healthcare costs underscores the dire need for automation. That’s where generative AI can make a huge impact.
Challenges with Traditional Inpatient and Facility Claims Review
Many factors contribute to the complexity of inpatient and facility claims. Consider multiple hospital stays across numerous healthcare providers, plus downstream health claims related to various tests. These make sorting through patient claims highly challenging.
Due to the complex, time-consuming nature of inpatient and facility claims audits (it can take up to three weeks to manually complete just one review), this large segment remains relatively untouched by technology solutions, representing up to 45% of costs in healthcare. As a result, they are done selectively – typically limited to high-dollar thresholds.
On average, it takes a clinician 15 to 30 days to review just one inpatient or professional claim during the course of an audit. The tedious audit process involves multiple steps, including gathering and cross-referencing medical records, coding provided medical services, requesting documentation, calculating the reimbursement amount, submitting the claim to insurance companies, and communicating claim status to patients. It’s not only an inefficient process, but there’s a lot that can go wrong, leading to denials, billing errors, and increased costs.
Enter Gen AI. It can automate tedious, time-consuming tasks by gathering and scouring all the necessary documentation and cross-referencing claims data from multiple sources. This level of automation will drastically reduce the need for manual review, streamline workflows, and increase accuracy and efficiency. In the medical claims audit world, this means faster, more accurate audit findings.
Generative AI Outcomes for Payment Integrity: What To Expect
Codoxo’s Clinical ClaimPilot, for example, can streamline audit services by 84%. Instead of spending weeks on just one audit, health plans can complete medical billing audits in less than 24 hours, resulting in more than 20 audits per day. This means an average health plan can increase the total number of complex healthcare claims audits from 5,200 per year to an astounding 32,500, driving significant ROI.
Today, conducting internal audits and external audits using traditional methods can have an average savings impact of $37 million. With generative AI, such as Clinical ClaimPilot, healthcare organizations can realize on average 4x more – $163 million. This is game-changing.
The Opportunity Awaits You – Gen AI for Payment Integrity
There’s no question – Gen AI is revolutionizing health insurance, including payment integrity. Now is the time to embrace this emerging technology and start reaping its many benefits – from automating complex manual tasks to generating astronomical savings and new opportunities.
At Codoxo, we’re on a mission to future-proof payment integrity with generative AI to make healthcare more affordable and effective. We’re here to help you navigate your own AI journey to take advantage of AI-driven solutions that reduce costs and power a more efficient healthcare future – a transformation that’s long overdue.