This multi-dimensional analytic capability can also be applied to quickly emerging overutilization trends.

The sheer volume of claims also makes this new type of analytics valuable. For example, overutilization trends in use of transcutaneous electrical nerve stimulation (TENS) for chronic pain management could be mitigated by using AI-driven analytics to leverage social posts, peer-reviewed journal outcomes, and claims-related insights., in order to significantly increase the effectiveness of audits, target higher propensity to overpay claims, and eliminate dead-end searches.


APIs, interoperability, and NLP drive efficiency
Program integrity innovations now focus on the increasing ability of health plans to obtain medical records directly from the EHRs of providers with whom they have value-based contracts. That interoperability enables the automation of common tasks such as prior authorization and records requests to determine the medical necessity of services. This kind of automation can save many hours of work for reviewers and coders at health plans.

The time savings can be increased by another 40 percent when AI-led natural language processing (NLP) is applied to unstructured data in the initial stages of review. So, while increasing the hit rate for identification of anomalies, a system that incorporates AI and NLP can also increase staff efficiency and reduce the use of high-cost resources such as nurses.

Augmenting AI capabilities with multidisciplinary engagement
It’s important to note that an investment in new or upgraded technologies or analytics alone is insufficient to address the task at hand.

Health plans seeking real financial improvement and administrative efficiencies need to seamlessly couple technology with service capabilities and workflow improvements across the claims processes. Health plans will have to integrate payment integrity as an enterprise-wide initiative, starting with provider credentialing, special investigation units, customer complaints teams, and utilization management – all the way to post-service claims administration services.

Most important is engaging service providers that have the global delivery capacity to deploy the clinicians and high-skilled examiners to intervene in high-impact claims and behavior management. The clinical reviewers look at site of service, level of care, and medical necessity protocols and help providers get on a path toward a collaborative approach. They engage in benchmarking and ranking providers on a longitudinal scorecard, as well as engaging in peer review analysis.

Artificial Intelligence Homepage