Unlock the power of AI in your payment integrity program

Payer organizations continue to lose billions of dollars each year to errors, waste and fraud – a gap that payment integrity (PI) programs are striving to close. Today, however, most PI programs still rely heavily on manual processes to identify billing and payment errors, making claims audits slow, labor-intensive and full of wasted effort.

Leaders recognize that there’s a better way. We recently partnered with Healthcare Dive to survey 150 executives from commercial, private, individual/family, Medicare Advantage and Medicaid Managed Care health plans about the challenges that their organizations face in building effective PI programs. We learned that payer organizations are looking to adopt new technologies to help them catch errors earlier in the payment lifecycle and create additional efficiencies.

To achieve this kind of digital transformation at scale, they’ll need to unlock the power of AI. Infusing generative AI (genAI) into PI processes across the value chain will make it possible to find more savings with speed and accuracy, extract valuable insights and enhance audit operations.

The need: greater efficiency and productivity

The majority of respondents to our survey are already leveraging digital tools in their efforts to improve audit selection rates and operational efficiencies. As many as 77% employ tools that are intended to boost auditor efficiency.

Still, using the solutions that are standard across the industry today, an experienced claims auditor can rarely complete much more than 20 DRG audits per day. Most of this time is spent gathering data from claims, medical records, provider contracts and coding/reimbursement policy documentation, as well as sorting and organizing the information to determine which of it is relevant to the claim at hand. This can mean searching for hours for specific facts that are buried within hundreds, if not thousands, of pages.

The future of payment integrity

Health plan executives understand that these processes are inefficient, and that claims auditors could be far more productive by automating manual processes, improving selection accuracy, and empowering PI professionals with AI-driven insights. In fact, 92% of respondents agreed that genAI will make payment audit and review processes faster (without compromising accuracy) within the next one to two years.

Advanced digital capabilities, including AI and genAI, are no longer visionary concepts but live practices transforming the PI industry. Harnessing the power of data and AI, PI programs can process complex, high-volume claims with unparalleled accuracy and speed across diverse datasets and at every stage of the claims lifecycle.

AI-led digital solutions will dramatically increase selection accuracy rates, giving auditors a clear view —from the very start — of real-time, data-driven insights that extend far beyond traditional claims review to uncover hidden risks, detect errors and potential fraud schemes, and minimize improper payments With these new technologies in place, the job of claims auditor will also change, focusing more on domain expertise and less on routine administrative procedures. By employing a human-in-the-loop approach to AI, PI professionals can focus on making critical decisions, with minimal time spent gathering and collating data, while staying at the forefront of these industry-changing innovations.

This data-led, digitally enabled approach will empower payment integrity operations to scale. When claims selection is driven by machine learning and AI, record requisition will be digitized and streamlined, and there will be far fewer refund recovery bottlenecks. Overall, workflows will no longer be manual and disjointed. Instead, they’ll be centralized, automated and value-generating.

EXL’s digital solutions, powered by genAI

EXL payment integrity solutions are putting this vision of the future into practice today. Taking this approach, EXL has been able to grow its customers’ cost-of-care savings over 300% per billion dollars of intake since 2021. These very same capabilities can be extended to help scale any payer operation to produce greater recovery volumes faster.

For a more in-depth look at the state of payment integrity today, download the full survey report here.