AI Generates $260 Million in Fraud Savings in 2019

AI in healthcare has enormous potential to streamline and enhance payment integrity efforts for healthcare payers. Healthcare fraud, waste, and abuse cost healthcare payers $300 billion every year. In an era of rising costs and shrinking margins, healthcare payers must reduce fraud, waste, and abuse to stay competitive and provide care for their members, and artificial intelligence can serve as an enormous force multiplier for payment integrity efforts. 

Let’s look at how one healthcare payer has leveraged artificial intelligence to increase the efficiency of their payment integrity operations, with impressive results. 

AI in Healthcare Payment Integrity

Highmark, a health insurer and integrated delivery network in the mid-Atlantic region, has deployed AI within its Financial Investigations and Provider Review (FIPR) department in recent years, with impressive results. In 2019, Highmark used AI to generate $260 million in savings by preventing fraud, waste, and abuse charges. In the last five years, their AI implementation has saved over $850 million. 

They’ve accomplished these impressive results by using cutting-edge AI technology to detect potential fraudulent healthcare claims and activity more quickly and efficiently than traditional payment integrity methods. Based on the success of their AI efforts, Highmark is further investing in and deploying new technological tools for the identification and prevention of fraudulent healthcare billing. 

Highmark’s solution melds human know-how with technological efficiency. Their internal payment integrity team includes subject matter experts, including nurses, accountants, former law enforcement officers, medical billing and coding experts, and IT specialists. They leverage AI technology to audit unusual claims and possible coding anomalies. 

A review of Highmark’s payment integrity programs, conducted by Change Healthcare, showed that Highmark’s AI-powered approach outperforms industry norms, saving ten percent of medical claims for group customers and generating 33 percent more savings than typical national payers.

Outsourcing Payment Integrity: A Scalable Solution

AI in healthcare is a game-changer. 62% of healthcare industry executives have adopted an AI-centric strategy in their organization, up from 33% in 2018. However, AI development is expensive and time-consuming. Highmark is one of the top ten health insurers in the United States, with the resources, personnel, and scale to develop and implement bespoke AI tools. Not all healthcare payers have the resources to do so. But all healthcare payers face the challenges of medical fraud, waste, and abuse costs, and with the right payment integrity partner, any healthcare payer can leverage the power of artificial intelligence. 

Artificial intelligence works best at scale. AI trains itself by ingesting vast amounts of data, and its value lies in its ability to sift and analyze data far more quickly and efficiently than human analysts. The technology is too powerful for healthcare payers to ignore its potential, and by partnering with a proven payment integrity specialist like Alaffia Health, this technology can help any healthcare payer of any size lessen their fraud, waste, and abuse costs. Even healthcare payers that do have the resources to develop an in-house solution often choose to partner with a payment integrity specialist instead of re-inventing the wheel.

AI In Healthcare: Proven Partners Create Powerful Results

Alaffia Health offers an advanced AI-powered payment-integrity-as-a-service platform that integrates with legacy and enterprise systems to provide a true turnkey solution. Our AI technology scans high-cost claims most likely to contain fraud, waste, and abuse charges and flags anomalies for further analysis by our expert team of payment integrity analysts. We obtain documentation, fully review the claim, and advise the provider on the correct billing amount, generating immediate savings for healthcare payers that partner with us. 

AI can be an intimidating field. However, healthcare payers who are slow to adopt this transformative technology will be left behind. Partnering with Alaffia Health brings you unparalleled payment integrity expertise while avoiding the time and cost of developing your own AI in healthcare. Best of all, Alaffia Health works on a contingency-based fee structure, so we only get paid for results.

It only takes a few minutes to learn how you can turbocharge your payment integrity program with the power of artificial intelligence. Schedule a call with Alaffia Health today.