Case Studies AI Claims Adjudication Increases Revenue, Cashflow, Saves Man Hours

AI Claims Adjudication Increases Revenue, Cashflow, Saves Man Hours

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AI claims adjudication was implemented to address the challenges faced by a large independent pathology lab in managing denied claims and improving cash flow. Two claims adjudication models were developed to prioritize denied claims based on various factors. The models were successfully integrated into the lab’s workflow and automated, leading to a 45% increase in the speed of revenue cycle management. Additionally, accounts receivables increased by 8%.

Critical Issue

A large independent pathology lab faced challenges with unhealthy working capital and poor cash flow due to difficulties in collecting accounts receivable for denied claims. There were too many denied claims and insufficient resources to process and resubmit them to the payor. The team of 30 revenue cycle management teammates could only handle 40% of the 10,000 denied claims received every month. This left 60% of potential revenue uncollected as claims had to be reviewed, fixed, and resubmitted to the payor, highlighting inefficiencies in the revenue management process.

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Customer Profile

Large independent pathology lab in the US

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Key Problems

Unhealthy working capital and poor cashflow

Can’t collect accounts receivable for denied claims

our solution

Two claims adjudication models were created and activated to prioritize denied claims through factors such as the likelihood of payout, contractual amount owed, adjudication complexity, and payment timeline. These models now operate in a production environment, are fully automated, and seamlessly integrated into the user workflow. Additionally, a randomized control experiment was developed to gauge the economic return on investment.

The implementation of these models was completed within a 12-week timeframe by a team of 2 individuals, utilizing a tech stack consisting of Azure, Databricks, Python, and SQL to enhance the efficiency and effectiveness of the claims adjudication process.

The results

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By leveraging technological advancements, revenue cycle management now operates 45% faster

and has successfully increased accounts receivables by 8% without requiring additional resources.

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