AI, Automation, and The Future of Prevention
Throughout this six-part series, we’ve dissected denial trends, quantified the staggering costs, and laid out the People and Process strategies needed to achieve a zero-tolerance mindset toward preventable errors. In this final part, we address the ultimate enabler for modern revenue cycle management (RCM): Technology.
When faced with the challenge of “Half the Staff,” technology is the force multiplier that allows a small, highly effective team to manage a growing volume of claims, maximize prevention, and finally “Turn Data Into Dollars.”
1. The Technology Imperative
Technology is the third and final pillar of the People, Process, and Technology (P-P-T) framework. Its primary goal is to automate repetitive, high-volume tasks and provide predictive analytics that flag errors before a claim even leaves your system.
Effective technology in a denial-prevention context includes:
- Automated Eligibility Checking and Verification of Benefits.
- Sophisticated Claims Edits (scrubbing).
- Denial Management System Workflow.
- AI/RPA (Robotic Process Automation) for high-volume, low-complexity tasks.
2. Prevention at the Source: Claims Edits and Eligibility
The most critical preventative tool in your RCM stack is Claims Edits, also known as claim scrubbing.
- How it Works: The claim scrubber is an automated system that scans claims to detect and correct errors or inconsistencies before they are submitted to the payer.
- What it Catches: It checks for code accuracy, valid patient and provider demographics, correct modifiers, and ensures compliance with specific payer-specific rules and medical necessity guidelines.
- Eligibility Check: An integrated system must check for Active Coverage and a Verification of Benefits file for every encounter. Failure to verify coverage is one of the top causes of preventable denials.
3. The AI Advantage: Dynamic Claims Edits and Coding
Artificial Intelligence (AI) and Machine Learning are transforming standard RCM tools, making them predictive and adaptive.
AI-Enabled Claims Edits
Traditional claims edits are rule-based and static, requiring manual updates whenever a payer changes a policy. AI-Enabled Claims Edits are fundamentally different:
- Dynamic and Learning-Based: They use predictive analytics and automatically adapt to new regulations and payer rules based on historical data.
- Higher Accuracy: This allows them to identify complex, evolving, and nuanced errors that a static system would miss, significantly reducing manual effort and boosting accuracy.
AI in Coding (Reality Check)
AI is often marketed as a full replacement for human coders, but the reality is more nuanced:
- Speed and Efficiency: AI coding software excels at automating routine coding tasks, freeing up certified coders to focus their expertise on complex, ambiguous, or rare cases.
- Shared Reliance: Both AI and human coders rely heavily on the quality and completeness of the clinical notes and medical records. If the documentation is poor, the code—whether machine or human-generated—will be inaccurate.
- Oversight is Required: Both AI and human coding require continuous learning, oversight, and quality checks to maintain accuracy and compliance.
When evaluating an AI coding solution, you should look for core features like AI-powered code suggestions using NLP, built-in audit and compliance checks, and a vendor that guarantees 95% accuracy or better.
Your Path to Financial Improvement with UnisLink
This series has shown that the vast majority of denials—up to 90%—are preventable. The monetary losses due to denials typically range between $75K to $200K per provider annually.
The solution to achieving financial success, even with limited resources, is to embrace the philosophy: Get it right the first time. Do it once. By combining the right People with documented Processes and enabling them with sophisticated Technology, you can build a clean claims strategy that is resilient, efficient, and profitable.
To help you put this plan into action, we’ve developed tools to assess your current performance and build a strategy for prevention.
Ready to Take Action?
Download our complimentary resources to start your denial prevention journey:
- Denial Management Whitepaper: Read the full guide on denial strategy
- Denial Formula Worksheet: Calculate the true cost of your denials
Ready to tackle your medical billing denial challenges? Download our free denial management whitepaper to gain a deeper understanding of these issues and learn actionable strategies to improve your practice’s financial health.
Download your free copy of “Navigating Denial Management: An Essential Guide for Physicians” to gain actionable insights and proven strategies for building a healthier, more profitable revenue cycle.
This is just the beginning of our deep dive into medical billing denials. Be sure to subscribe to our blog to stay up-to-date with the rest of this five-part series!
Contact us today to learn more about UnisLink medical billing services and how to rightsize your practice for outstanding financial performance.