Artificial Intelligence (AI) IN RCM OPERATIONS
On Demand | Service Offerings
Prior Authorizations
Red Flags
Prior Authorization (PA) delays, burdensome documentation requests, frequent change requirements, or inadequate staffing to process PAs?
Real-Time Proactive Approach:
≥ 98% of authorizations should be reviewed and processed timely, accurately and efficiently.
Eligiblity Verification
Red Flags
Inaccurate and outdated data encounters causing eligibility verification and processing issues?​
​
Data Correction Approach:
≥ 98% of patients insurance should be registered, verified and validated prior to visit, or services being rendered​
​
Medical Claims Data Entry
Red Flags
Medical Claims Rework due to data capture issues, incomplete claim errors, invalid insurance information, or improper code use?
​
Proactive Claims Clean-Up Approach:
Verify, validate and reconcile data integrity risks to ensure claims are reprocessed and resubmitted for optimal reimbursements​.
Documentation Integrity (CDI)
Red Flags
Over-reliance on AI-Powered Clinical Documentation Integrity (CDI) software? Insufficient transparency? Are AI in CDI performance issues putting you at risk?
​
Data Compliance Approach:
CDI Chart Review 90%,
Query Rate, determined by CDI Dept
Provider Response Rate 95%
Provider Agreement Rate 80%
Unable to Determine Rate 5%
AI in Medical Coding
​​Red Flags
Inadequate EHR system integration, not adhering to AI in medical coding DNFC, regulatory updates and insufficient AI systems training?
​
Real-Time Coding Audit Approach
Minimize coding delays on all
Discharged Not Final Coded (DNFC) Accounts
​
≤ 5 Day Benchmark tracking/trending missing documentation in real-time Prioritize high-risk/high-dollar accounts and cases​​
Charge Integrity
​​Red Flags
Inaccurate Coding, Billing, and Documentation discrepancies causing revenue losses, and increased operational costs due to claim rejections and denials?
​
Accuracy, Speed & Efficiency Approach:
24-Hour charge capture reviews and charge reconciliation turnaround times daily, Meeting all billing, claims processing & timely filing deadlines.
Claims Management & Denials Management
Red Flags
Incomplete and inaccurate claims data, failure to verify and validate patient information properly, or failure to track, analyze and trend denials?​
​
Proactive Monitoring Approach
Establish clear accountability guidelines, review and follow up procedures to improve claims management and denial discrepancies
Claims Scrubbing
​Red Flags
Not understanding or adhering to payer guidelines, overlooking common errors, failure to review rejected claims and post payments properly and timely?
​
Risk Identification Approach:
Review and analyze UB-04 and CMS-1500 claims data patterns and improvement opportunities.
Outsourced Vendor
Management
Red Flags
Ineffective Communication, unresolved issues, confusing contract and SLA details. Failure to provide ongoing performance monitoring and metric checks and balances?
​​
Retrospective Performance Review Approach
Establish SLA KPIs, manage, monitor and meet performance standards, Conduct Regular SLA audits to ensure regulatory compliance standards are met.
​