A 2018 Gartner report estimates that 3% to 7% of all paid claims dollars in Payer commercial business are improperly paid. The Centers for Medicare and Medicaid Services (CMS) calculated a 9.5% claims payment error rate in 2017, which contributed to $36 billion in overpayments.

The simple reason for these payment frauds is that most Payers have traditionally invested in outdated Payment Integrity models, which have failed to correctly classify member eligibility, detect contractual gaps, or identify pricing errors. With this approach, the expected savings do not materialize even if these Payers automate their redundant processes.

Could Artificial Intelligence technologies help control the Payer industry’s rising costs? How can AI intervene in ways that actually result in better healthcare outcomes? Is AI is applicable for the pre-payment cost avoidance model too?

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