Can AI Manage High-cost Claims? Not Without Humans

April 22, 2024 - High-cost, in-network claims are an ongoing challenge for providers and payers. These claims are often complex, demanding significant documentation and scrutiny.

As the volume of high-cost claims grow, payers need an effective approach for managing them. A strategic partner that leverages the right technology and the right people can deliver the solution they need.

The Rise of High-Cost, Complex Claims

What is driving the rise of high-cost, complex claims? The answer to that question can be seen in part in billing practices. There is a noticeable increase in billing medical claims at higher intensity levels.

This trend is noticeable in inpatient, outpatient and specifically emergency department settings. In 2004, one in five outpatient office claims were billed at level 4. In 2021, 38% of claims in the same setting were billed at level 4, according to the Peterson-KFF Health System Tracker. The same analysis found that level 4 and 5 claims make up the majority of emergency department claims in 2021.

The Peterson-KFF Health System Tracker analysis found that the price of these higher-level claims is increasing at a faster rate than the price of claims billed at lower levels.

Untangling and addressing the issues driving high-cost, complex claims is no simple matter. Billing practices may account for part of this trend, but there is also an aging population with complex care needs to consider.

High-cost specialty drugs also have a role to play. Spending on specialty drugs hit $301 billion in 2021, half of all drug spending that year, according to data from the Office of the Assistant Secretary for Planning and Evaluation.

Strategies like preventative care, early intervention and care coordination could address mounting healthcare expenditures and the rise of high-cost claims. However, these approaches take time and considerable resources to put into practice. In the meantime, high-cost claims still need to be managed.

Technology-driven Expert Claims Review

High-cost claims generate massive amounts of data. Finding billing errors and discrepancies can be akin to wandering through a continuously growing maze. The right technology can potentially identify those issues faster than a human.

An expert claims review team that uses AI-driven algorithms built to find inaccuracies and inconsistent billing practices is able to drill down to the facility, claim and patient levels. “The technology can help drive data to tell you where to look, where the outliers are or where things don’t make sense,” says Brian Rubio, vice president of product at Zelis.

Healthcare billing practices and the regulatory landscape are constantly changing, challenging payers to keep up as they review the influx of high-cost, complex claims. Technology must keep pace with that change to give payers the support they need.

“You need to keep evolving, especially in the prepay world where if you have an outdated algorithm and the claim comes in, you’re not going to get it right,” adds Rubio.

Where People Make the Difference

Technology, like AI, is a vital tool in the claims review process, but it cannot solve these challenges alone. Together, human experts and AI can help grapple with the volume, complexity and nuance of reviewing high-cost claims.

Technology helps human experts find trends, discrepancies and inaccuracies. Then the people on the Expert Claims Review team use their clinical knowledge to verify accuracy and ensure billing aligns with industry standards and payer customizations.

Just as technology evolves to keep up with the changes in the billing landscape, so do the human experts. The claim reviewers at Zelis delve into the current literature and provider policies to stay up to date. “They’re constantly reviewing medical records and leveraging peer-review expertise when needed,” says Emily Ehle, PharmD, vice president of operations for Expert Claims Review at Zelis.

People and technology can work seamlessly behind the scenes, but human intelligence adds another essential dimension to managing high-cost claims. People are relationship builders. The people staffing the Expert Claims Review team at a strategic partner like Zelis establish trusted connections with thousands of providers.

Knowing that a person can pick up the phone and speak to someone in a provider’s medical records office is invaluable.

“If you don’t have trust, then you end up potentially increasing abrasion with the provider and costing time and expense for all parties to be able to get what you need, which goes against what we stand for. There ends up being just a lot more waste in the system,” Rubio observes.

A Powerful Partnership

Technology and people: one without the other is insufficient to handle the demands of managing high-cost claims. But together, this powerful partnership can deliver payers the answer to these demands.

Processes driven by intelligent technology and human expertise can generate savings by ensuring billing accuracy and reducing the administrative burden of claims review. That accuracy and increased efficiency ensure providers get reimbursed faster and correctly the first time, further strengthening those relationships.  

As billing practices shift and regulatory frameworks change, the right strategic partner for high-dollar and complex claims reviews makes sure that payers never fall behind. “Taking that two-prong approach allows you to modify and keep on top with the [trends that are] coming out,” says Rubio.

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Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts. To learn more about the 2024 Best in KLAS payment integrity and accuracy solution and how we help drive accurate payments, click here.