How generative AI and RPA are transforming claims appeals
Building a faster, stronger, better revenue cycle
Managing clinical claims appeals is a costly and convoluted function of the healthcare revenue cycle, requiring the time and attention of clinicians and support staff who otherwise could be focusing on higher-priority tasks.
Introducing generative artificial intelligence (AI), or GenAI, into the claims appeals process can reduce the administrative burden on clinicians and staff and improve the efficiency and accuracy of appeals.
With a more streamlined appeals process, healthcare organizations have the potential to increase reimbursement and enable more seamless interactions with payors.
From automation to AI in the revenue cycle
AI builds upon the foundation set forth by robotic process automation (RPA)
Despite some shortfalls in its capabilities, RPA technology has made great strides in reducing inefficiencies in health systems’ revenue cycles and reducing administrative friction with payors.
Now, organizations are taking the next step by integrating generative AI to optimize revenue cycle performance.
RPA
Eliminates human error
Automates redundant and repetitive tasks
Gathers and manages data efficiently
AI
Leverages existing RPA, technology, and security infrastructure
Learns and improves over time
Makes predictions from its knowledge base
RPA + AI
Alleviate the administrative burden on highly credentialed providers
Strengthen claims appeals
Streamline the revenue cycle
AI and healthcare claims appeals
How does it work?
Combining human intelligence with automation, generative AI draws on RPA capabilities and clinicians’ clinical expertise to draft timely claims appeals with less administrative effort from providers.
1
Payor denies claim
2
RPA receives denial and prompts AI to understand the cause
3
RPA securely gathers key info from the electronic health record (EHR)
6
AI drafts appeal letter
5
RPA sends summarized information and cause for denial to AI
4
RPA prompts AI to summarize key information from EHR
7
RPA creates a document for review
8
Appeal is sent to a human approver for final review
9
The appeal document is sent back to the payor
What are the benefits?
To address rising healthcare costs and complexities, healthcare organizations need solutions that provide value across the organization and to their patients and their families.
Patient and provider experience
Revenue and cost-savings
Quality
Clinicians:
Free up time spent on administrative tasks, reducing burnout and improving job satisfaction.
Modernize and elevate the physician role and responsibilities.
Lower the cost to collect.
Increase the speed and volume of collections.
Improve denial overturn rate.
Expedite favorable appeals decisions.
Reduce avoidable losses.
Improve the accuracy and timeliness of claims appeals, reducing friction with payors.
Extend high talent resources by offering attractive positions with competitive pay and fulfilling employment opportunities.
Key considerations
As healthcare organizations consider AI use cases, an enterprise strategy is essential to ensuring they have the infrastructure, governance, and people to support and seamlessly integrate the technology.
Elements of an AI strategy
Strategic alignment
Data
management
Ethics
End user design
Change management
Metrics and reporting
Click to explore the key considerations
Strategic alignment
Engaging key business functions and clearly articulating the goals of implementing AI, ensuring they align with broader business objectives.
Data management
Establishing a robust data management strategy focused on quality, storage, security, and governance.
Ethics
Developing guidelines and policies to address the ethical considerations of AI, such as bias.
End user design
Prioritizing human-centric design to promote adoption.
Change management
Investing in enablement and training to articulate what AI is and how to use it safely and effectively.
Patient and provider experience
Metrics and reporting
Establishing metrics and reporting mechanisms to regularly measure performance and identify improvement opportunities.
Strategic alignment
Administrative staff:
Increase productivity enabled by streamlined workflows.
Patients:
Ease patient anxiety with an expedited patient claims resolution.
Leverage innovative technologies to improve dated systems and processes.
Elevate the employee experience by prioritizing top talent for more impactful and patient-centric assignments.
Click to explore the benefits
Expedite favorable appeals decisions.
Reduce avoidable losses.