Artificial intelligence in Medical billing, for now, may create a template chart for the medical biller to review and draw the attention to the details where it should be and bring more focus on revenue driven processes where it can eliminate the repetitive nature of work such as eligibility check or report generations which is time and resource consuming. But this still does not mean that human oversight will be eliminated because of Ever changing guidelines, rules, regulations, and system adaptability with different levels of coding and modifiers and their interpretation to billing process and also until the full confidence is gained into the AI technology.

Yes, Artificial intelligence and Medical billing will co-exist for considerable amount of time and it is yet to be seen whether a complete take over by AI will be possible. However, AI will make an impact on Human jobs where jobs cuts to certain numbers are impending in Medical billing industry but due to other factors such as government legislations on employment and economical factor can limit to which AI can take up the positions in the industry.

Medical Coding Drives Medical Billing in RCM

Medical billing and Medical coding are two different parts of one Engine which is RCM-Revenue cycle management and for the engine to produce the driving force for the medical practice and providers, one part has to function correctly for other part to produce results because of their dependability on each other. If for some reason, the Coding part is not correct due to AI, the end result will also be compromised either in form of Denial, rejection, or legal repercussions.

Artificial Intelligence (AI) In RCM

Artificial intelligence can certainly optimize the RCM, but not all. For example, it can schedule and data capture rather quickly and error fee (not always), but question is, will it be able to do the eligibility check especially when some inherent mistake are there on patient details in the system already? Will AI be able to prior authorize, even sometimes Doctors/providers do not know or mention the requirement of prior authorization on the services they intend to provide?

Prior authorization is the resource and time consuming job, especially if the online web portal is not available. Will the eligibility check come back ok, even if the patient exist in the system? Same goes for Doctor note interpretation, which requires good analytical, cognitive and critical thinking to understand it correctly to later transform in Medical bill, especially in cases of denial, where providers might be tempted to up code if insurance think that there was no medical necessity for that particular service and this is where experience medical biller can help avoid legal issues instead of Artificial intelligence in RCM.

Automation VS AI In Medical Billing

For Medical billing side in RCM, the automated tools/software’s are in place which prevents denials and rejections such as Claim scrubbers, Charge scrubbers – (identifies the error in the claim themselves before it is submitted with the insurance/payer for their review). It is basically the job of claim scrubber to audit the medical bills/claims to ensure accuracy.

As claim scrubbers are critical parts of clearing houses and if for some reason the claim gets stuck in the Claim scrubber with all the automation and experience gained over years with the use of this technology, the Human oversight will be required to have it cleared from scrubbers. With this, although AI is a different concept and is based on different algorithms then automation, it is again designed by Humans, it did not come into existence by itself, it is genetically prone to make mistakes and it will require a human mediation, at least for some time to come.

In this particular AI case, where claim is stuck in clearing house scrubber, for the correction and for the claim to pass to the payer for adjudication, since there are no hard and fast rules and every claim is different and requires different information such as existence of ICD 10, CPT codes and then it verifies that CPT, ICD 10 and HCPCS codes among other administrative payer requirements to be processed correctly for claim to not to be denied, the AI system cannot update itself to the level where claims pass through the clearing house unless it develops the cognitive and analytical understanding and thinking for all the information related to claim and why it is held up in claim scrubber to be precise.

For example, if the Date of birth format is wrong, the AI base tool may go on to correct that, but if the name is incorrect on the claim and for some reason, the name is also incorrect on the payers system, The AI based tool will be unable to correct that mistake without the intervention of the Human being and on top of that different payers have different rules which changes over time so again human intervention is likely factor here.

How Artificial Intelligence (AI) Can Make difference in Medical Billing?

Number 1 medical billing denial reason still to date is Data capture etc. demographics. AI based tools, unless they develop the cognitive capabilities, analytical reasoning and critical thinking, will be unable to deal with this denial reason. If we look at the AI about 2 years ago, it could not filter out one payer with specific rule, which had to applied on all payers. But now it has the ability to do so, but again it is not 100% efficient due to ever changing guidelines, rules and regulations, legislations, and with the introduction of new codes (after approval of CPT Editorial panel) and sometimes CPT category II and Category III codes certainty it is far from applicable as standalone solution for practices.

For that factor, AI is not going to do all the work for you, it will filter out some of the work but human involvement would be necessary. AI will make the process faster over time but if one say it will take care of all the tasks, that for now, is not close to reality. AI may eventually get there but that will take some considerable amount of time but human factor cannot be discarded.

Since Artificial Intelligence (AI) in Medical billing is good on Repetitive jobs such as copying electronic medical records and pasting it where it is required. This way Acritical intelligence can certainly increase efficiency, staff productivity, improve accuracy, certain level of claim management where data accuracy needs to be checked and can help increase the scalability of practice by letting more patient registration with same number of staff and can send the statements out on it’s own.

Preparing Reports

Preparing reports manually can be a time consuming and daunting task. AI can play a vital role by saving time and generating the reports all by itself. It can even send the reports by itself without the human interactions as long as the data on which these reports are being complied are correct. In this case the team working on reports can work on more productive work such as cross verifying the data capture, charge scrubbers and revenue driven processes.

Artificial Intelligence And Compliance

An article in RAC Monitor "RAC Audits and EHR Software – Who Bears the Burden of Non-compliance?" which states that Bot or AI based softwares may not be as dependable. They may not be as adept on Privacy and security side as other expect and can be non complaint on electronic signatures. Also, the extensive use of hacking these days, with malwares, ransomwares the privacy and security of the patient record can be at serious risk if software firewall is breached which not only can cause serious HIPPA compliance but also Monetary penalties and in some cases the imprisonment.

Artificial intelligence and Wrong data Entry

Although there is wide understanding and rightly so that AI softwares should not make mistake on data entry, but as per the Article - RAC Audits and EHR Software – Who Bears the Burden of Non-compliance?, the Author has found that some of the repetitive jobs such as self-populating fields cannot be error free.

Government legislations and employment status

One of the factor in US as how economy is performing is the number as to how many jobs are created. Although, AI is unlikely to discard the human factor but it is inescapable that it will eat up some of the jobs from the Medical billing industry. However, governments can not let their people without jobs if AI becomes widespread and there is very likelihood that legislations will soon be incorporated to support the human factor to what percentage in one organization AI can factor in and also More jobs means better economy, more tax collection and prosperous society.