Author: Michelle Allan, Principal

 

In the dynamic world of governmental oversight, managing risks and reducing errors are crucial for ensuring compliance. Recently, these risks have become more pronounced in the Medicare Secondary Payer arena due to increased governmental scrutiny and new legal enforcement measures. Even minor typographical errors can lead to penalties and other significant liabilities.

Our most recent technology research at Allan Koba Compliance Solutions has targeted Medicare Conditional Payment resolution as a key area prone to manual processing errors. Many businesses rely on manual human processing to review vast amounts of tedious codes and data in voluminous Medicare Conditional Payment Summary Forms, determining whether the company or the government is responsible for making medical expenses. We have accomplished savings of hundreds of thousands of dollars for insurance companies in even one Payment Summary Form – See Impact of Section 111 Reporting on Conditional Payment Resolution. Any given claims program could process hundreds, if not thousands or tens of thousands of Payment Summary Forms per year, with millions upon millions of dollars in play. With this much at risk, businesses can’t afford mistakes.

According to the Harvard Business Review, human error accounts for 80% of the most prominent risks businesses face, including cyberattacks. This study highlights that collaboration between human and machine intelligence is essential for safeguarding businesses from risks while blending innovation with human expertise to enhance results.

In our internal product development research, we’ve found that integrating a human-assisted artificial intelligence platform into these processes is a game-changer. Here’s how AI can help:

  1. Enhanced Data Accuracy and Processing AI algorithms excel at handling vast amounts of data with precision. By automating data entry and validation, AI minimizes human errors that often occur in manual processes. This is particularly beneficial in Medicare Conditional Payment resolution, where accurate data is crucial for compliance and reimbursement accuracy.
      • Human Error in Data Entry: Manual data entry is prone to errors, with studies showing error rates ranging from 1% to 5%. These errors can lead to significant financial and operational inefficiencies. For instance, even a 1% error rate in processing 10,000 entries means 100 errors, which can have substantial repercussions.
  2. Improved Risk Assessment and Fraud Detection AI can analyze patterns and anomalies in data to identify potential risks and fraudulent activities. Machine learning models can continuously learn from new data, improving their accuracy over time. This proactive approach helps insurance companies detect and mitigate risks before they escalate.
    Given the resurgence of the False Claims Act in Medicare Secondary Payer discussions,
    the timing for incorporating AI into your compliance program is optimal.
  3. Streamlined Claims Processing AI-powered systems can automate the claims processing workflow, from initial submission to final resolution. Natural Language Processing (NLP) can extract relevant information from documents, while image recognition can assess damages. This not only speeds up the process but also ensures consistency and reduces the likelihood of errors.
  4. Predictive Analytics for Better Decision-Making AI can leverage predictive analytics to forecast trends and outcomes based on historical data. This enables insurance companies to make informed decisions, optimize their strategies, and better manage their resources. Allan Koba Compliance Solutions has the technological capabilities to identify outcome probabilities, adding another tier of valuable information for human decision-making.
  5. Compliance and Regulatory Adherence AI systems can be programmed to ensure that all processes adhere to the latest regulatory requirements. This is particularly important in Medicare Conditional Payment resolution, where compliance is critical. AI can monitor changes in regulations and automatically update processes to remain compliant.

 

Conclusion: Integrating AI into traditionally manual data processing compliance protocols offers a multitude of benefits, from reducing errors and enhancing data accuracy to improving risk assessment. Allan Koba Compliance Solutions is at the forefront of Medicare Secondary Payer compliance, leveraging human-assisted AI to lead to more efficient operations, better compliance, and ultimately, a more protective program. Want to know how Allan Koba can improve your Medicare Compliance program? Reach out to us at: info@allankoba.com