How AI for health plans benefits payment integrity
According to a recent study, 61% of surveyed payment integrity leaders believe there are untapped cost savings opportunities beyond their current solutions. The good news is, health plans leveraging artificial intelligence (AI) in payment integrity have a greater ability to tap into those opportunities. AI for health plans offers a range of benefits for the payment integrity process, including:
- Improved view of plan activity
- Streamlined claims processing
- Optimized claims edits
- More effective FWA detection and prevention
- Accelerated document review
- Continuous improvement
Improved view of plan activity
AI-powered data analysis enables health plans to assess plan data, government data sets as well as other external data sources to uncover trends and activity with greater accuracy, leading to optimized decisions and reduced potential losses. Shift leverages over 100 external data sets to improve analysis.
Streamlined claims processing
AI accelerates claims processing, reduces manual intervention, minimizes claim processing time, and improves customer satisfaction. For example, health plans using Shift AI experience over 60% increase in workflow efficiency.
Optimized claims edits
Over 1/3 of surveyed payment integrity leaders see policy management and administration as a main challenge. AI can analyze healthcare policy, plan guidelines and other documents needed to keep claims edits up to date with the evolving healthcare landscape - strengthening claims editing systems and maximizing savings.
More effective FWA detection and prevention
Increased accuracy with AI results in 96% alert qualification rates. AI's advanced analytics detects anomalies and patterns to identify potential FWA trends and activity, safeguarding the integrity of claim process and payment, and increasing savings related to FWA-related losses and resources.
Accelerated document review
55% of health payer tech leaders think large language models (LLMs) will have a transformative or disruptive impact on the healthcare industry overall. One application of LLMs is in document review. AI and Generative AI accelerate document, image, and medical record reviews by quickly identifying key areas, highlighting concerns, bookmarking sections for further review, or flagging for potential misuse or manipulation.
Continuous improvement
AI continuously learns from pre and post payment outcomes to enhance payment accuracy throughout the claims lifecycle, continually refining decision intelligence and driving improved outcomes for plans.
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