What Is Machine Learning (& How Does It Help Payment Integrity?)

Machine Learning in healthcare payments

Alaffia Health’s investment in machine learning and other artificial intelligence technologies delivers unparalleled results in preventing and recovering healthcare fraud, waste, and abuse costs. Their next-generation AI-driven payment integrity platform enables their expert team of payment integrity analysts to review and audit claims quickly, efficiently, and accurately. 

AI is a collection of related technologies that leverage advances in computing power, speed, and memory to automate work tasks. How does AI work? How can it empower advances in healthcare billing? And how does AI enable Alaffia Health to achieve top-tier results? Let’s look at how Alaffia implements artificial intelligence to protect their partners from fraud, waste, and abuse costs. 

What Is Artificial Intelligence? 

Artificial intelligence is a broad and often-confusing term. It generally refers to computer processes and systems that mimic human behaviors such as problem-solving, learning, planning, and pattern recognition. 

AI is very useful for tasks with the following three attributes.

  • Repetitive
  • Rule-based
  • High-volume

There are several types of technologies lumped together under the umbrella term of AI. 

  • Machine learning: Machine learning is the process by which a computer system teaches itself how to accomplish a task. There are a variety of approaches used to accomplish this. The common thread is using advances in computing speed and data processing to teach a computer how to accomplish the desired task/process. 
    • Deep learning: Deep learning is a subset of machine learning. This type of program utilizes neural networks to simulate how a human brain analyzes a problem. Deep learning systems break down natural language, visual images, and/or other inputs into their components to seek context and extract meaning, trying to improve the computer’s accuracy in arriving at the correct output or conclusion. 
  • Natural-language processing: Natural language processing is a term for computer processing that interacts with written/spoken human languages naturally without the need to input/output their data in code. Alexa or Siri are examples of natural-language processing at work in consumer spaces. Instead of typing search queries into a text field, for example, one can just ask Alexa and it parses the question and provides potential answers. 

How Does Machine Learning Assist With Payment Integrity? 

Machine learning has been revolutionary in many sectors, including healthcare; the ability for computers to ‘teach themselves’ to recognize discrepancies and process documentation at a far higher rate than any human analyst serves as a powerful force multiplier. Machine learning is invaluable for risk analysis, fraud detection, predictive suggestions in apps and websites, and targeted marketing. In healthcare, machine learning is used for new approaches to treatment, diagnosis, and patient experience. 

Machine learning is a key technology for Alaffia’s payment-integrity-as-a-service platform. Sifting through large quantities of data very quickly, it uses machine learning to identify medical claims that contain potential fraud, waste, and abuse costs. It conducts initial audits of high-dollar, error-prone medical claims and flags those with a high probability of containing erroneous charges. This allows Alaffia’s team of payment integrity analysts to focus their efforts for a significant increase in efficiency. 

Alaffia’s team of medical billing and coding experts and payment integrity analysts parse through claims flagged by the platform, conducting itemized reviews of each claim and its supporting documentation. We provide a detailed report to healthcare providers and establish the correct amount to bill the healthcare payer. We also provide a detailed report to the payer with the correct amount they should pay and the savings delivered by Alaffia. 

The Bottom Line

Artificial intelligence isn’t easy to implement. Machine learning only works when the computer can teach itself the right data. Many healthcare payers  find a payment integrity partner is the most efficient way to leverage these technologies for their organization. 

Payment integrity is Alaffia Health’s sole focus. We have a proven, established turnkey solution that integrates with healthcare payers’ existing systems for immediate results. We provide real-time data on past and current claims and actionable insights on fraud, waste, and abuse trends over time. And our contingency-based fee structure means we only get paid when we generate savings for your organization.

Book a call with Alaffia to find out how you can leverage the power of machine learning for your organization’s bottom line.

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