Published on
Highmark Health is finding that artificial intelligence (AI) can influence reimbursement, according to Modern Healthcare. The integrated system’s insurance unit posted an operating loss that was tied to higher utilization as well as an increase in coding accuracy coming from providers in their claim submissions. Thanks to AI, providers are more likely to submit cleaner claims that better reflect the reality of clinical care and patient acuity—which also may incur higher reimbursement. It’s not fraud, according to insurance executives at Highmark; it’s better administration and documentation that previously has been too much trouble to wrestle through without the benefit of AI.
Split the difference: “One of the promises of AI in healthcare is that it improves the accuracy and completeness of coding,” says Alan A. Ayers, MBA, MAcc, President of Urgent Care Consultants and Senior Editor of JUCM. “But services delivered with this code capture, which benefits providers, must also be paid. As payers deal with ‘claims inflation’ to maintain profitability, they must either raise premiums or reduce contracted rates. Some have even discussed payers soon requiring special codes when AI touches a chart, which would reduce reimbursement and effectively split the productivity gains of AI between providers and payers.”