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 payment processes – 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 that will help free healthcare teams 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 towards 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 expenditures correlating with a rise in hospital stays, which has led to increased in-patient and facility claims. In fact, the number of such claims, along with the cost of hospital and in-patient care, has grown in the last decade, with an estimated 589 million in-patient 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 in-patient 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 costs all underscore the dire need for automation. That’s where generative AI can make a huge impact.
Challenges with Traditional In-Patient and Facility Claims Validation
Many factors contribute to the complexity of in-patient and facility claims. Consider multiple hospital stays across numerous care teams, plus downstream health claims related to various tests. These make sorting through patient claims highly challenging.
Due to the complex, time-consuming nature of in-patient and facility claim 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 in-patient or professional claim during the course of an audit. The tedious process involves multiple steps, including gathering and cross-referencing information, coding provided medical services, requesting medical records, reviewing documentation, calculating the reimbursement amount, submitting the claim to insurance and communicating claim status to patients. It’s not only an inefficient process, but there’s a lot that can go wrong, leading to payment delays and increased costs.
Enter Gen AI. It can automate tedious, time-consuming tasks by gathering and scouring all the necessary documentation and cross-reference 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 facility claims audit world, this means faster, more accurate claims validations and audits.
Generative AI Outcomes for Payment Integrity: What To Expect
Codoxo’s Clinical ClaimPilot, for example, can streamline audit efforts by 84%. Instead of spending weeks on just one audit, health plan teams can complete clinical 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 clinical audits from 5,200 per year to an astounding 32,500 – driving significant ROI.
Today, conducting in-patient and facility audits using traditional methods can have an average savings impact of $37 million. With generative AI, such as Clinical ClaimPilot, health plans 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 healthcare, 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.
