Healthcare professionals need to be aware of the heightened hazards brought on by the increased usage of artificial intelligence (AI) in the industry. The managing director of Berkeley Research Group, Thomas F. O’Neil III, emphasizes the necessity for healthcare provider organizations to comprehend the risks connected with AI and the requirement for control. O’Neil talks about healthcare compliance procedures, AI-backed reimbursements, and AI-enabled claims management systems. Healthcare boards need to be thoroughly informed about and educated about how their organization uses AI to process claims or for reimbursement.
As Artificial Intelligence (AI) is used more frequently in healthcare, healthcare provider organizations must be aware of the dangers it poses and the need for oversight. The managing director of Berkeley Research Group and a compliance specialist and AI concerns, Thomas F. O’Neil III, discussed the value of oversight when integrating AI systems in the healthcare industry.
One of the areas where AI is being used in healthcare is AI-backed reimbursements. AI-backed reimbursements are model-enabled reimbursement amounts that leverage large volumes of data to predict the expected payment. This is possible by automating the rate-setting procedure using previous claim data. To automate rate-setting by region, city, etc., CMS may, for instance, change Medicare’s fee-for-service methodology to utilize an algorithm that takes into account local socioeconomic variations.
Although AI can be a helpful tool in healthcare, there are ethical considerations that healthcare boards must be aware of. These considerations include informed consent to use data, safety and transparency, algorithmic fairness and biases, and data privacy. The board or governing body must oversee the organization’s strategic initiatives and risk management program. They must be adequately informed and educated about their organization’s deployment of AI in reimbursement or claims processing.
AI-enabled claims solutions are another area where it is being employed in healthcare. By improving workflow quality and accuracy, automation of laborious but necessary operations can hasten the processing of claims and payments. By analyzing previous patterns and alerting significant personnel to impending denials, AI can also help in the forecasting of claim denials, allowing claims to be revised before billing. When utilized properly, AI has the potential to be a useful tool for compliance officers, as it can lead to improved communication with governmental regulators and enforcement agencies as well as streamlined processes.
Hospital price transparency became effective on January 1, 2021. The regulations require hospitals to make their standard charges public with a shoppable, consumer-friendly display of at least 300 medical services. Additionally, hospitals must make standard charges public with a comprehensive, machine-readable file. The laws could still be improved, even though they are now effective. By holding listening sessions to get feedback from patients and their families on the most effective methods to present information, CMS is continuing its efforts to make sure hospitals adhere to the criteria for transparency.
Price transparency has generated a new spectrum of compliance risks for health systems. Health systems are required to disclose to the public a bewildering array of extremely precise requirements under the price transparency legislation. The development of user-friendly software within electronic health records by health IT can support health systems’ efforts to increase price transparency. Reliable and well-integrated software will not only boost compliance with pricing transparency regulations but also enable participants and providers to locate the most affordable treatment options.
Healthcare boards must oversee the deployment of AI technology in compliance processes and related billing and claims processes. They must receive sophisticated, incisive reports from senior management regarding the deployment of AI technology in compliance processes. Additionally, healthcare boards should consider adding learning and development opportunities to enrich their directors’ understanding of AI and how it can be utilized in healthcare. As this technology continues to develop and evolve, the best way to oversee it is to understand it as well as possible.
