Payers and providers are stuck in a tug of war over claims, with AI as the driving force for each side.
Revenue cycle technology continues to evolve and innovate, and payers are keeping pace adopting artificial intelligence and pitting automation against automation.
With tools like AI algorithms, payers can deny claims in large batches and without human input.
“There is immense potential for generative AI and automated solutions in healthcare,” Kim Rometo, senior vice president and technology officer for the Atlanta Hawks and State Farm arena, said during the 2023 HealthLeaders Revenue Cycle Technology Exchange in November. “From streamlining tasks to increasing operational efficiency, flagging patient biases, and even counteracting payer algorithms or solutions that make it difficult to approve claims.”
In November, United Healthcare came under fire when a federal class action lawsuit was filed against them. Allegedly, after purchasing an AI algorithm to evaluate insurance claims, older patients’ claims for doctor-recommended stays in extended care facilities were wrongly denied, leaving patients with unexpected medical debt.
A statement from the Clarkson Law Firm, the firm that filed the lawsuit, explained that there’s a 90% reversal rate when these denials are appealed and that only 0.2% submit their claims for appeals. Additionally, medical oversight is only introduced during the appeals process.
“While AI technology holds incredible promise to advance the healthcare industry, United Healthcare’s algorithms is a prime example of the real harm it is causing when left unchecked,” Glenn Danas, partner at Clarkson Law Firm, the firm that filed the lawsuit, said in a statement.
Many revenue cycle leaders voiced their frustration with payers algorithms during November’s exchange. During his presentation to attendees, Jonathan Benton, assistant vice president of Atrium Health, provided five methods leaders could use to combat payer issues.
Jasmyne Ray is the revenue cycle editor at HealthLeaders.