Health plans are witnessing a tremendous increase in volume and complexity of claims. Demographic changes, complex coverages, shift to value-based contracting and evolving regulations are challenging administrative teams across the claims value chain. To maintain process integrity, efficiency and accuracy, plans will need to look beyond traditional manual, sample-based audit processes that are hard to scale.
Exponential AI’s Decision Agent driven Audit solution can scale claims audit processes to cover 100% of claims volume. The audit solution helps audit teams find and deliver all error claims for audit and action.
Audit that works for you
Decision Agent based AI solution
- The audit center provides an intuitive interface for auditors to manage their workload, recommendations, across the claims lifecycle.
- All agent identified claims have error labels that hint to probable root cause/error source and cover administrative, clinical and contract errors.
- The audit center allows auditors to provide feedback to digital agents to continuously learn and improve error claim discovery and error category identification.
- The Audit solution comes with a dashboard to monitor Key KPIs across the audit lifecycle. Insights are provided right from intake, tracking up to resolutions.
- Detailed insights on performance and outcomes of digital and manual audit processes, including financial, operational and decision insights available from audit to upstream processes.
- The reporting dashboard is easily configurable and customizable for your unique process needs.
- The operations centre delivers capabilities to manage the audit process across digital and manual audit. It enables managers, supervisors, process owners to allocate and track cases flagged for audit.
- The centre enables configuration of prioritization and routing based on parameters like financial value, recovery potential, risk or new anomalies.
Drive Measurable Business Impact
Maximizes overpayment recovery, reduces improper payment waste,
and promotes provider satisfaction
Reduction in lead time
Optimizes investigatory workflow by bringing only the most complex files and issues to the attention of investigators and analysts
Decrease in Audit Costs
Provides experienced, highly trained decision agents to make most decisions, allowing auditors to focus on exceptions.
Reduction in Financial Leakage
Uses AI to enable prepay avoidance and early identification and risk mitigation of new errors or anomalies.
100% Audit Impact in week not months
Ready To GO
An out-of-box solution that comes with a smart start mechanism to start delivering value immediately. It works independently without integration with existing systems.
Built For Your Process
Works with your existing investments and can easily be customized for your requirements. You can configure and train our decision agents to follow your policies.
Scale To 100% Oversight
Go from sample-based audit to 100% in weeks. Enable audit teams to focus on error claims and save audit time currently wasted on clean claims.
Transparency, Control, Ownership
Experience touchless audit customized for your process. Drive transparent, explainable and trusted audit recommendations.