AI Has Its Place at the Table, With Humans

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The importance of accountability in healthcare claims remains steadfast, especially as erroneous claims, fraud, billing mistakes, improper payments, and overpayments cost billions of dollars annually in the United States. Yes, making sure providers are paid promptly and protecting patients remain paramount, but so does adding accountability to claim submissions to wrangle the unnecessary costs to the system from inaccuracies and fraud.

As we look to technologies to assist in the claims review process, there is misunderstanding about the use of artificial intelligence (AI). First and foremost, there needs to be a clearer understanding of the role of AI and machine learning in healthcare claim submission review. Second, we need to accept that companies helping health plans with these reviews have widely varying approaches. And, finally, communicating the loss of those billions of dollars each year is essential for garnering continued support of appropriate healthcare claim submission review services to reduce the ripple effect of inaccurate payments for us all. This needed clarity was reinforced swiftly after reading a recent article in Modern Healthcare, “AI does what insurers ask. Providers say that’s the problem” (Nona Tepper, January 2022), with contributing quotes from many industry experts.

To level set, there will be no commentary regarding the specific disputes highlighted in the article, but instead referencing the article’s content as a springboard for further discussion about the use of AI in the claim submission review process and also to reinforce the importance of appropriate, timely submission review services. At Nokomis, we focus on claim accountability for health plan clients and we do not believe AI can stand alone in this space. While AI can be justified as part of identifying suspicious inaccuracies, it cannot be used as the sole basis to automatically change any billings. Every single claim review must stand on its own. Taking the findings from 5 claims and somehow extrapolating those findings and applying them to other claims is inappropriate; they need to be reviewed one by one and, importantly, in a timely manner. And, what’s most important? If AI does identify a pattern, requesting those medical records for an expert (human!) team to review is the only way to be certain before recommending an action to reduce or deny a claim.

Dan Howell, a partner from consultancy West Monroe, is quoted in the Modern Healthcare article: "On top of these systems, some insurers have implemented AI or machine learning to scan multiple claims and identify reimbursement patterns, which they can then use to influence payment policies." If that is in fact happening, it is again, inappropriate. At Nokomis, the only way to ensure claim accountability is to allow the technology to inform our team of the possibilities in findings, then that same human team of expert reviewers fully reviews medical records to understand more about the code, service, or policies in question. Technology influencing policies is egregious without the holistic approach of medical records review to see what’s going on before a health plan makes, reduces, or denies a payment. When it comes to claims, why should a plan pay for a half-day of counseling and treatment when the patient was onsite for only 45 minutes?! That scenario lets everyone down and we see it time and time again.

The article also interviews Chip Kahn, President and CEO of Federation of American Hospitals, who is paraphrased expressing his belief that “growing technological sophistication of insurers’ claims processing systems is responsible, in part, for increasing the number of payer and provider disputes in 2021.” A health plan should be working with a company that offers customizable solutions so that plans stay in charge of provider and member communications and decision making on which claims are denied. Plans have unique contracts with providers across the board and any claim submission review company they’re using to help with identifying inaccurate claims should be able to understand and customize to meet the needs of those contracts.

Having an independent review from a claim accountability review company allows an unbiased eye from the health plan to further review items in question; this isn’t a “gotcha” approach to finding minutia claim mistakes, but instead looks deeper into a claim that might seem fine when in fact it does not have adequate documentation or the service stated was not provided. Why should the system as a whole pay repeatedly for unnecessary labs and higher-than-necessary ER levels?!

There’s fear that AI alone is denying claims in the system. Assuming we all want more claim accountability throughout the system, then making a difference through a holistic approach of unique technology plus human record review in a timely manner is the preferred approach. Nokomis’s expert team works to get to the bottom of discrepancies and inaccuracies in claims before recommending adjustments or denials. Simply paying for claims that might appear fine at the surface is not justified either, so digging in and understanding why a claim raises concern is vital. While it might be more convenient to just pay claims that look okay at face value, inappropriate payments, especially fraudulent ones, are a real issue and create wasted dollars in an already expensive industry.

The reality is that accurate claims need to be processed swiftly so that providers are paid in a timely manner. At the same time, improving claim accountability submissions overall reduces the wasted dollars in the system and stops supporting those individuals who are not providing patients with the services submitted.

Clarity around the importance of increased claim accountability is a mission at Nokomis because it keeps all players in the care journey responsible for their part. Technology is only part of the equation, but it does have a place, and must be used in tandem with a human team of experienced reviewers for claim accountability to improve. Furthermore, on the provider side, offering more consistent staff training on billing and coding, especially as changes occur, is essential. Patients also need to know what their coverage is and how their out-of-network coverage works while taking responsibility for reviewing claims on their behalf. Finally, health plans need to spend each dollar wisely and hold providers accountable for billing inaccuracies while maintaining strong relationships.

One of the core values behind claim accountability at Nokomis is combining innovation and human expertise. When all players in the healthcare system holistically approach how we can fairly and effectively marry technology and human experience, we begin to have a more accountable healthcare system for all.