AI Products

AI Clinician Assistant

AI RCM

These are companies that use AI to automate billing. In general companies in this category are RCM vendors more advanced AI capabilities to their existing products. These applications include:
- Continuously monitoring payer-specific rules and updating claims routing processes
- Reviewing claims and automatically fixing errors
- Evaluating collections against clinical data and capture potential underpayments
- Automated appeal processes
- Automation of patient collections, including delivery of statements and management of patient interactions

AI Billing

AI Clinical Documentation Integrity (CDI) products leverage artificial intelligence to review and evaluate clinical documentation in support of appropriate patient care, billing, and compliance with regulatory requirements. 

These solutions can operate at the point of care, ensuring the documentation reflects the patient-clinician conversation and available clinical data, and supports the assigned medical codes. They can also operate post-encounter, between the medical coding and billing steps, to review the documentation against what has been coded and surface suggestions for revenue and quality opportunities. Many of these solutions include built-in functionality to suggest potential diagnoses that may have been missed based on information in the patient record.

While similar in concept to risk adjustment solutions, AI CDI products are predominantly used in a fee-for-service context to ensure more accurate and complete billing and improve care quality.

AI Clinical Documentation Integrity

These are companies that use AI to automate medical coding or improve coding efficiency and outcomes. 

Vendors using AI for medical coding vary meaningfully in their service coverage, with nearly every vendor covering certain specialties like radiology and pathology but very few taking on more complex encounters such as inpatient stays.

AI Medical Coding

These are prior authorization platforms for health plans and other entities that do utilization management. They use AI to automate UM decisions and improve efficiency of UM nurses / clinicians. Functions usually include:

- Ingestion of clinical policies and translation into decision trees
- Automatic population of prior auth decisions for approval
- Automatic approval of auths that meet certain criteria
- Documentation of decision reasons, i.e. traceable decisions

Prior authorization vendors vary meaningfully in their service coverage, with some specialized for pharmacy and others focused on certain types of medical services.

AI Prior Authorization for Providers