The Standard

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.

How AI for Deterministic Approaches Can Fix PA Denials

A recent survey by the American Medical Association (AMA) revealed a growing concern among physicians: over 60% believe that unregulated AI tools are systematically denying necessary patient care. “Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care,” said AMA President Bruce A. Scott, MD, reacting to the survey results.

This alarming trend exacerbates the already burdensome prior authorization (PA) process in the US, delaying essential treatments and placing undue strain on providers, payers and patients alike.

At Smile Digital Health, we believe that AI should support—not override—good medical judgment. That’s why we developed KALM Services (Knowledge Authoring Lifecycle Management), with AI capabilities designed to exponentially accelerate the creation of deterministic computable policies for prior authorization workflows and other use cases like clinical reasoning and quality measure evaluations.