AI-enabled Healthcare Claims Processing Solution

For a leading provider of integrated business solutions in this domain, the need to minimize HIPAA-related risks while enhancing operational efficiency became a top priority. EvoluteIQ stepped in as the trusted partner, offering an AI-enabled solution that would transform healthcare claims processing.

The Results

Data capture

91% data capture accuracy, reducing manual processing


40% reduction in claims document handling

HIPAA violations

60% drop in HIPAA violations within 3 months of go-live


Gartner prediction

By 2025, the 10% of enterprises that establish AI engineering best practices will generate at least three times more value from their AI efforts than the 90% of enterprises that do not.

EIQ Features Used

The Challenge:
Confronting Accuracy Hindrances: Minimizing HIPAA Violations Through Automation

The client grappled with accuracy issues that had led to a surge in HIPAA violations. Manual handling of claims documents had been a persistent issue, particularly concerning Protected Health Information (PHI), causing complications related to turnaround time. The overarching objective was to minimize operational inefficiencies and transition toward a “first time right” approach, where precision and compliance are paramount.

Our Solution:
HIPAA Compliance Meets Efficiency: Implementation of an AI-Enabled Workflow

EvoluteIQ Intelligent Business Automation for AI-enabled Automation for Healthcare Claims Processing

The EIQ platform enabled an AI-enabled workflow tailored for healthcare claims processing. This advanced workflow was strategically designed to streamline intricate claims processing tasks, offering an efficient and accurate approach.

The automated handling of the case documents package significantly reduced the need for manual intervention. To further enhance the accuracy and reliability of decision-making, the existing OCR technology was replaced with a superior system. This ensured structured data extraction from the often unstructured medical bills and supporting documents.

The extracted data, encompassing patient information, bill lines, and associated CPT/ICD codes, underwent rigorous processing using a complex business rules engine. This intricate step was vital to ensure that every piece of information was accurate and compliant with industry standards. Moreover, the system facilitated the conversion of this data into specific formats suitable for seamless downstream processing.

Additionally, the solution included an automated audit trail creation mechanism, a crucial element in maintaining compliance with stringent regulatory requirements. As confidence in the system grew, the manual quality control processes were gradually reduced or eliminated in a planned manner, marking a significant leap toward greater efficiency and reliability.

Are you ready to transform how your business operates?

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