Ensuring financial health: the role of Gen AI in payment integrity solutions in healthcare

A national health insurance payer manages millions of claims annually. Despite their size and experience, they are grappling with significant inefficiencies and errors in their claims’ payment process. For a payer, these issues lead to frequent overpayments and underpayments, causing financial strain and damaging relationships with healthcare providers.

Their claims processing team is overwhelmed with manual verification processes that are time-consuming and prone to human error. The existing system lacks real-time data validation and cross-referencing capabilities, making it difficult to catch mistakes before payments are made. Additionally, the complexity of varying contract terms and pricing agreements contributes to the high error rate.

This is a typical example of how important payment integrity is in claims management. It helps keep your money healthy and ensures that you pay claims on time, without problems, and accurately. It involves rigorous checks to verify that claims are paid correctly, according to policy terms and billing guidelines. This means spending money on advanced data analysis and fraud detection technologies to find mistakes and stop overpayments or false claims.

Effective payment integrity programs help in reducing unnecessary spending, improving member satisfaction and upholding the payer's reputation. By making claims processing more accurate, healthcare payers can improve their efficiency and manage healthcare funds better.

Current industry challenges of payment integrity

Payment integrity in claims management is a problem for healthcare payers. It affects how well their operations work and how much money they make. One major challenge is the complexity of billing codes and regulations, which can lead to errors in claim submissions and reimbursements. This complexity requires payers to keep up-to-date knowledge and use advanced systems to handle the details of coding and regulatory changes well.

The prevalence of fraudulent claims poses another challenge, as they not only strain financial resources but also compromise the quality of care. “In the US, the National Health Care Anti-Fraud Association (NHCAA) estimated that 3% of the total healthcare expense is lost in claims’ frauds”. Detecting and preventing fraud requires advanced analytics and continuous monitoring, which involves substantial investment in technology and skilled personnel.

To address such challenges, healthcare payers are increasingly turning to automated solutions and gen AI to enhance accuracy, reduce costs and improve the overall efficiency of payment integrity processes. Leverage workflow automation and generative AI to develop innovative solutions that significantly improve payment integrity.

Luckily, the latest advances in automation and technology offer strong solutions to make payments easier to use and better at finding and stopping fraud. Fortunately, cutting-edge advancements in automation now provide robust tools to streamline payments, detect fraud more effectively and safeguard financial resources.

The power of intelligent automation using GenAI

As we look to the future, payment integrity is poised to revolutionize health claims, driving accuracy and efficiency through advanced analytics and automation and fostering a more transparent healthcare ecosystem.

1. Real-time data validation: Automated systems can cross-reference claims data against member eligibility, benefits, and historical data in real time. Real-time validation not only reduces errors but also speeds up claims processing time, improving cash flow and reducing administrative backlogs.
2. Contract and pricing compliance: Integrating contract terms and pricing agreements into the verification process of automated systems ensures that each claim is paid accurately based on the agreed-upon rates. This not only saves money but also strengthens relationships with healthcare providers by ensuring fair and timely reimbursement.
3. Duplicate claims detection: Duplicate claims are a common source of overpayments. Advanced systems can identify and flag duplicate claims, preventing double payments and reducing financial losses.
4. Clinical Language Pro: NTT DATA CLP is tool leverages advanced NLP technologies to transform unstructured clinical data into structured, actionable insights. It is designed to assist healthcare providers, researchers, and administrators in extracting valuable information from medical records, clinical notes, and other health-related documents.

Enhanced fraud detection and prevention

1. Machine learning algorithms: Machine learning algorithms can analyze vast amounts of claims data to detect anomalies and suspicious patterns. These tools can flag fraudulent claims for further investigation, helping payers mitigate financial risks and maintain the integrity of their payment processes.
2. Predictive analytics: Predictive analytics can identify high-risk claims and providers before fraud occurs. By analyzing patterns and trends, these tools can alert payers to potential issues, allowing them to take proactive measures to prevent fraud. This proactive approach not only saves money but also improves the overall security of the payment system.
3. Comprehensive audit trails: Automated systems maintain detailed records of all claims processed, including any adjustments made. With a clear record of every transaction, payers can quickly identify and address any discrepancies, further improving payment integrity.

Streamlining payment integrity

1. Dashboard and analytics: Real-time dashboards and analytics provide insights into payment trends, error rates, and other key performance indicators. This data-driven approach enables payers to make informed decisions, optimize processes, and continuously improve payment integrity.
2. Integrated workflows: Automated systems can integrate seamlessly with existing workflows, reducing the need for manual intervention. This not only improves efficiency but also reduces the risk of human error.
3. Continuous improvement: The latest technology allows for continuous improvement in payment integrity. By regularly updating algorithms and incorporating feedback, payers can ensure that their systems remain effective and relevant.

Conclusion

Business Process Services is at the forefront of changing payment integrity with workflow automation and generative AI. These technological solutions are changing how healthcare organizations manage their payments. They are making processes easier, more accurate, more reliable, and more efficient. As the healthcare industry continues to evolve, using advanced technologies like workflow automation and generative AI is essential for staying competitive and achieving operational excellence.

NTT DATA leads in transforming healthcare payment integrity with automated workflows and generative AI. Our solutions streamline processes, boost accuracy and compliance, enhance fraud detection and start operational efficiency. Embrace these technologies to stay competitive and achieve excellence.

Read the IDC Spotlight paper to learn how payers can adopt a predictive approach to reduce efforts and costs and improve member and provider experience. By understanding the "why" behind the numbers, payers can enhance their financial integrity, detect anomalies, and make data-driven decisions that drive better outcomes. Visit our BPO for Health Plans webpage to learn how you can implement generative AI solutions into your payment operations. You can also read Nelson Hall’s NEAT report  to know how we have transformed healthcare payer operations.