Penrod Blog

How Healthcare Providers are Utilizing Artificial Intelligence to Improve the Claims to Payment Process

Why AI needs to be in your claims

AI in Claims Data illustration

As technology advances, healthcare providers turn to artificial intelligence (AI) to optimize their revenue cycle process. One key area where AI can significantly contribute is in the “claims to payment” portion of the process, which includes claims optimization, billing, payment, and denials management.

In this article, we’ll explore how healthcare providers utilize AI to improve these areas of the revenue cycle process.

Claims Optimization

One of the ways AI is being utilized in the healthcare revenue cycle process is through claims optimization. AI can detect errors and omissions in claims before they are submitted. This includes identifying incorrect demographic information, inaccurate CPT codes, and incorrect provider information. Additionally, AI can analyze payer-specific claim billing patterns based on historical reporting and billing patterns and recommend edits on a payer-by-payer basis. This helps to ensure that claims are submitted correctly the first time, reducing the likelihood of rejections and delays.


Another area where AI is being used to improve the revenue cycle process is in predicting propensity for payment based on demographics and patient behavior. This helps to score patients based on how they are likely to pay, when they are likely to pay, and how much they will pay. This scoring system helps to identify claims that are unlikely to be paid, allowing staff to focus on patients that are likely to pay.

By identifying these claims early in the process, healthcare providers can work to resolve the issues and submit the claim more quickly, improving cash flow and reducing the likelihood of unpaid claims.

Patient Payment

In addition to improving billing processes, AI can also be used to personalize payment plans based on patient behavior. This includes effective engagement cadences, contact methods, and payment structures. By personalizing payment plans, healthcare providers can increase patient satisfaction and improve the likelihood of on-time payments. Additionally, personalized payment plans can help patients better understand their financial obligations, reducing confusion and frustration.

Denials Management

Despite efforts Finally, AI can be used to improve denials management by scoring denials based on the likelihood of being paid. This helps detail teams focus on the right claims and prioritize which claims should be worked on first. In addition to scoring denials, AI can also automate claims edits to prevent denials from occurring in the first place. This saves time and resources while reducing the overall cost of the revenue cycle process.

Our Final Take

In conclusion, healthcare providers are utilizing AI to improve the claims to payment portion of the revenue cycle process. By utilizing AI in areas such as claims optimization, billing, patient payment, and denials management, healthcare providers can improve cash flow, reduce the likelihood of denied claims and increase patient satisfaction. As the healthcare industry continues to evolve, AI will undoubtedly play an increasingly significant role in the revenue cycle process. Healthcare organizations that embrace this technology will be best positioned to succeed in the future.


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