The AI Solution to Insurance Capture Shortcomings

Processing insurance claims is notoriously difficult, especially in the healthcare industry. There is such a high denial rate that each year, there is a deficit of $262 billion generated from denied health care claims. Errors during patient registration, the first step of the submission process, account for 27% of these denials, which is an incredible $71 billion. The industry is sorely needing a way to eliminate these errors to save money and time. Artificial intelligence (AI) might be the right answer to these problems.  

There is a lot of reliance on human knowledge in conventional claim processing, which means that human errors are a major cause of claim denials. Deep domain expertise is necessary for the task of locating and documenting crucial information, such as insurance payer details and claim submission sites, as insurance cards frequently don’t have this essential information printed on them. If an insurance claims specialist misrepresents the information, the claim will be denied, and there will be a financial loss. 

Insurance companies such as BlueCross BlueShield, Medicare, and Tricare have strict geographical criteria that further complicate the procedure. Accurately identifying the state, municipal, and ZIP claim systems is essential for approval. Wrong inputs can also result in an immediate denial of the claim. With multiple Medicare and Tricare regions, each with unique multi-state localities, the national health insurance information reporting shows a concerning average error rate of 19.3%. 

The problem is exacerbated by the way that information is currently gathered. Digital systems, for example, cannot fully extract and decode data from insurance cards; employees must manually enter the data. Optical character recognition (OCR) systems, which are designed to quickly pull out relevant data, have a hard time identifying information that isn’t printed on a card. This is an issue because most of the relevant information isn’t on an insurance card in the first place. 

Artificial intelligence (AI) provides a powerful solution to these issues by reducing inaccurate coverage calculations and misidentification of information. AI systems are capable of gathering, verifying, and processing insurance data more efficiently and more accurately than their human counterparts. It is even capable of processing information in as little as five seconds, as opposed to five to fifteen minutes for manual processing. AI can also provide massive cost savings by reducing the need for reworking claims, which typically cost $25 each to complete. Hopefully, after AI’s implementation, the healthcare insurance industry will see some drastic improvements.