How Technology Impacts Medical Claims Management

Technology plays a transformative role in streamlining medical claims management. Cutting-edge tools like Artificial Intelligence (AI), automation, and predictive analytics are now fundamental to achieving faster, more accurate, and cost-efficient claim processes. Here’s how these technologies impact each stage of claims management and the AI platforms driving this revolution.

How Technology Impacts Medical Claims Management

Claim Intake and Submission

• Optical Character Recognition (OCR) for Data Extraction: OCR technology scans and extracts information from medical forms, invoices, and receipts. For instance, a medical provider submits a claim for surgery expenses, and AI auto-populates fields like patient ID, diagnosis codes, and treatment dates, reducing clerical workloads.
• Automated validation ensures accuracy, reducing manual errors. Systems instantly cross-check data against predefined rules, such as verifying whether the treatment matches the diagnosis. For example, if a claim lists a sprain diagnosis but includes high-cost surgical procedures, the system flags it.
• Predictive analytics flags incomplete or inconsistent submissions. AI identifies missing fields before submission, such as absent authorization codes, ensuring claims are complete

Eligibility Verification

• AI cross-references policy details with claims data and compares it with policy details in seconds. For example, a patient with a chronic illness submits a claim, and the system instantly confirms eligibility for pre-approved treatments.
• Automation confirms coverage eligibility and benefit limits. Suppose a policy has a $50,000 annual cap on physical therapy. Automation ensures submitted claims stay within the limits, providing alerts if thresholds are exceeded.
• Predictive models anticipate potential coverage disputes like overlapping coverage claims. For example, it might detect if two insurers are billed for the same service, flagging potential disputes for resolution.

Fraud Detection

• Pattern Recognition for Overutilization: AI flags cases like frequent, unnecessary MRIs for minor conditions. For example, a single claimant might repeatedly seek diagnostic tests unrelated to their reported injury.
• Behavioral Analysis: Predictive models assess patterns such as claimants submitting identical injury claims across multiple policies. An example might include an individual submitting back injury claims to several insurers simultaneously.
• Automation for Investigative Workflows: Once a claim is flagged, automation assigns it to a Special Investigative Unit (SIU), prioritizing cases with the highest risk scores. For instance, a flagged claim for duplicate billing immediately routes to an investigator.

AI Platforms and Tools

Are you wondering what these tools are? Here are some noteworthy AI platforms and tools utilized in various stages of medical claims management to enhance efficiency, reduce errors, an improve outcomes.

Cerner

Cerner provides comprehensive revenue cycle management, including automated claims processing, denial management, and contract management. It integrates with the Cerner Millennium ecosystem for seamless data flow and improved operational efficiency.

Experian Health

Experian’s AI Advantage platform focuses on automating repetitive tasks in claims processing and uses AI-powered algorithms to expedite decision-making. It also assists with claim denials and streamlines insurance eligibility checks.

NextGen Office

This platform is designed for small to mid-sized practices and features automated claim scrubbing, EHR integration, and denial management. It improves claims efficiency by integrating with laboratory services and payment gateways.

Majesco

Majesco also known as ClaimVantage offers a suite of products specialized in solutions for P&C, disability, and life claims management while adapting to ever-changing regulatory requirements.

Change Healthcare

Their AI tools focus on enhancing claims editing and coding accuracy, reducing rework, and enabling faster reimbursements. It also helps identify and resolve potential denials before submission.

Telus

From data collection to validation, they support ambitious AI programs that enable autonomous driving, GenAI model adoption, extended reality applications, insightful search, and digital customer experiences.

Check out our sources below:

Oracle Health. (n.d.). https://www.oracle.com/health/

Matthewson, A. (2024, September 11). Top 10: Claims automation platforms. InsurTech Digital. https://insurtechdigital.com/articles/top-10-claims-automation-platforms

Majesco.com. (n.d.). https://www.majesco.com/white-papers/core-modernization-in-the-digital-era/