FORT WORTH, Texas, Nov. 14, 2023 — Advancements in artificial intelligence (AI) and machine learning (ML) are significantly improving results and efficiencies for payment integrity in medical claims, according to CERIS, a CorVel company.
“CERIS leads the industry in leveraging AI and ML to automate tasks for greater efficiency and accuracy, to find patterns that may indicate fraud or systemic errors, to interpret medical language, and to summarize large amounts of information into actionable data,” said Steve Sutherland, Senior Vice President of Information Systems for CERIS, a Fort Worth-based company that has pioneered the use of this technology for payment integrity.
Sutherland notes, “Now, generative AI and machine learning are taking productivity and savings even further. For example, by efficiently using machine learning, we can more effectively identify claim combinations with high probability of upcoding, flagging them for review by the claim professionals. We can summarize medical documents, extract keywords, answer specific questions, and bring often overlooked items to the reviewer’s attention. As a result, payers can more efficiently pay medical bills that are accurate and appropriate for the claim.”
Already, optical character recognition (OCR) and document extraction have increased throughput significantly. Additional benefits to CERIS clients include improved accuracy, faster turnaround time, and increased savings ratios.
Incorporating this technology also allows review teams to spend less time on tedious manual analysis so that they can focus on higher-value, more enriching work that better serves client needs. By making their work more rewarding and meaningful, valuable employees have higher job satisfaction and are more engaged, improving employee retention. CERIS’ leadership in technology elevates the efforts of professional staff and improves the outcomes delivered to clients.
Speed and precision are essential for maintaining payment integrity in healthcare, where payers have a responsibility to promptly and accurately reimburse providers, thus avoiding time-consuming efforts to recover erroneous payments. Prepayment review is becoming the norm – making it even more important to determine if a bill is accurate in a timely manner. Utilizing these new technologies improves the process and the experience of payers and providers.
About CERIS
CERIS, a leader in both prospective and retrospective claims review and repricing, combines clinical expertise and cost containment solutions to ensure the accuracy and transparency in healthcare payments. Accuracy and validation services include itemization review, DRG validation, facility repricing, contract and policy applications, review of implants and devices, and primary payer cost avoidance. Its universal chargemaster contains billions of charge items from more than 97% of the nation’s hospitals, helping to ensure the accuracy and objectivity of each claim review.