Exponential AI

AI is transforming how we handle COB by improving both pre-pay and post-pay processes. 1. Pre-Pay COB Review: Focuses on cost avoidance by ensuring the appropriate adjudication of future claims. 2. Post-Pay COB Review: Identifies recovery opportunities through a retrospective review of past claims against new COB information. By integrating AI, health plans can achieve greater accuracy and efficiency, reducing costs and enhancing the overall claims process. #AI #COBManagement #CostAvoidance #ClaimsProcessing

Happy Thanksgiving! ?? May your holiday be filled with warmth, happiness, and the joy of togetherness. Here’s to a season of appreciation and continued success together.?

Health plans face costly challenges due to poor provider data quality. Manual processes lead to errors, delays, and downstream issues like member/provider dissatisfaction, claims problems, and compliance penalties. Our AI-powered Smart Provider Contracts solution streamlines contract loading, directory verification, and updates, improving data accuracy and operational efficiency. This directly enhances three key financial outcomes for health plans.? ? 95% Faster Contract Loading: AI streamlines contract processing, enabling rapid implementation and updates.? ? 10-30% Less Claim Interest: AI ensures timely and accurate contract integration, minimizing interest payments on delayed claims.? ? 3-5% Fewer Claim Adjustments: AI captures precise contract details, reducing errors and adjustments in claims processing.?

Around 5% of all claims require a Coordination of Benefits (COB) adjustment, and more than half of these issues are never identified, costing #HealthPlans billions. By leveraging #AI, plans can now proactively discover and validate changes in member records from both internal and external sources, identifying COB issues and determining primacy before a #claim is even filed. ? This proactive, prepay approach helps prevent #overpayments and avoids the costly pay-and-chase efforts triggered by incorrect claim processing. AI enables health plans to enhance accuracy, speed up settlement times, and significantly reduce financial losses. ? #HealthcareInnovation #AIinHealthcare #ClaimsProcessing #COBAutomation #CostSavings

From the initial request intake ?? to the final authorization decision ??, ?? AI can transform or simplify every step of the prior auth process: ?? Digitize PA requests. ?? Automate data checks. ?? Predict potential voids. ? Flag cases for manual review. The result? Smarter, faster, and more efficient Prior Auth approvals! ???? #ExponentialAI #PriorAuthorization #RealtimeAI #Automation #PreAuthorization #UtilizationManagement #HealthcareAI

Health Plans spend $3 billion annually to maintain provider data quality and contracts. ?? Provider contracts today are managed manually, impacting cost ?? and quality of provider data. The lack of quality and rigor in demographic information and pricing configuration results in compliance and administrative risks for health plans. Health plans grapple with provider contract loading complexities due to frequent amendments for new business ventures and unique contracts for each business line and insurance type. These complexities lead to extensive manual work, increasing the risk of errors ?? and slowing down contract processing, which impacts both payments ?? and compliance. Payers can now leverage AI to extract, validate, enhance, and load data from provider contracts ??, improving provider data accuracy and operations for plans. ????

Rise in complex and suspicious claims is leading to more manual investigations. Despite a low actual rate of fraud, waste, abuse, or error (#FWAE) in these #claims, plans incur significant costs on processing such claims and also risk unwanted abrasion.? #AI is revolutionizing this process by accurately predicting claims likely to be rejected, while processing clean claims automatically. Healthcare plans incorporating AI alongside traditional rule-based systems are seeing remarkable benefits: reduced revenue leakage, shorter turnaround times, lower costs, and a better stakeholder experience.

As AI scales to billions of transactions, supporting this expansion becomes untenable with traditional AI implementations, which are fragmented, slow, and lack clear business impact. Exponential AI is a real-time decision intelligence platform that tackles these challenges head-on. Its unique decision agent-based architecture helps build, operationalize and orchestrate AI faster. By co-locating AI applications and data on IBM Z servers and leveraging LinuxONE’s on-chip acceleration, Enso enables real-time decisions with high speed, low latency, and high availability. Its ability to seamlessly integrate with existing workflow systems, data warehouses, and transactional systems ensures it can be effortlessly used with current systems, driving higher ROI for enterprises Unlock Real-Time Value with Exponential AI. Learn more about Exponential AI & IBM LinuxONE -> https://lnkd.in/gUaSDd4z

Payers are using AI to track membership and coverage changes in real-time, enabling faster and more accurate COB identification and primary payer determination. Automating these tasks with AI speeds up COB, prevents errors and overpayments, and helps identify misdirected or overpaid claims. #AIinHealthcare #COB #Automation #HealthcareInnovation #BenefitsCoordination

Denials impact nearly 20% of healthcare claims. Most go unaddressed, resulting in up to 5% of net patient revenue lost – that’s $10M-$15M for a $500M organization. Outdated technology, manual processes, and shifting payer rules make denial prevention an ongoing challenge. AI offers a solution. By analyzing policy intelligence, historical denials, claims, and encounter information, AI can transform denial management for providers: 1. Identify Denial Risks Proactively: AI predicts likely denials and flags claims for adjustment before submission, reducing the number of rejected claims. 2. Pinpoint Root Causes: AI surfaces the underlying causes of denials and recommends pre-bill interventions to correct claims before they are sent to payers. 3. Increase Clean Claim Submissions: By identifying and rectifying errors early on, AI can achieve a 5x increase in clean claims, significantly boosting revenue and cash flow. Harnessing AI for denial management not only reduces administrative burdens but also dramatically improves financial outcomes for healthcare providers. #providers #revenuecyclemanagement #healthcareai #rcmsolutions #claimsai