New publication outlines opportunities for accelerating and improving the use of AI to support payment integrity and reduce fraud, waste, and abuse
Last week, HL7 International released a new report outlining the actions needed to fully realize the benefits of artificial intelligence (AI) in improving payment integrity and reducing fraud, waste, and abuse. Reducing Fraud and Improving Payment Integrity in Healthcare Through the Use of AI brings together insights from payers, providers, and technology experts to define AI opportunities and emerging solutions, current challenges, implementation strategies, and standards needed to increase transparency and trust.
“The U.S. spends more than $900 billion annually on administrative complexity, waste, and improper payments,” said Charles Jaffe, MD, PhD, CEO of HL7 International. “This publication identifies practical and standards-based approaches to harnessing AI for one of healthcare’s most persistent and costly challenges.”
Key recommendations from the report include:
- Developing standards for explainable AI in healthcare with specific transparency requirements and bias mitigation protocols.
- Creating standards and infrastructure for trust and verification of AI-generated results.
- Establishing frameworks for human-in-the-loop validation that balance automation with clinical expertise.
- Implementing pilot programs focused on provider-payer collaboration that create mutually beneficial scenarios for all stakeholders.
“HL7 FHIR offers a powerful foundation for AI models aimed at improving payment integrity and reducing fraud, waste, and abuse,” added J. Marc Overhage, MD, PhD, Co-Chair of the HL7 Strategic Initiative on AI to Counter Fraud and Improve Payment Integrity. “FHIR-based capabilities like traceability, validation, error reporting, data segmentation, and workflow integration make it possible to build smarter, more transparent systems.”
HL7 is calling on healthcare stakeholders to engage in cross-sector working groups and participate in pilots that demonstrate how AI applications, powered by interoperable data standards, can deliver faster, more accurate payment decisions.
“As healthcare costs continue to rise, we must double down on interoperability and responsible data sharing to power the next generation of AI tools,” said Janet M. Marchibroda, Co-Chair of the HL7 Strategic Initiative on AI to Counter Fraud and Improve Payment Integrity and Co-Chair of Friends of HL7. “Strategic initiatives like this are not only facilitating important dialogue, but also driving real-world action to improve quality, efficiency, and effectiveness, both in the U.S. and globally.”
This publication is a product of the HL7 Strategic Initiative on Use of AI to Counter Fraud and Improve Payment Integrity. This is one of three strategic initiatives launched by HL7 as part of its ongoing work to accelerate the responsible use of AI to improve health and healthcare.
