METHODS, SYSTEMS, AND COMPUTER PROGRAM PRODUCTS FOR PROCESSING MEDICAL CLAIM DENIALS USING AN ARTIFICIAL INTELLIGENCE ENGINE
A method includes receiving a plurality of payment denials for medical claims from a plurality of payors; assigning, using an artificial intelligence engine, priorities to the plurality of payment denials, respectively; assigning, using the artificial intelligence engine, the plurality of payment denials to a plurality of agents responsible for obtaining payment approvals for the medical claims for which the payment denials have been received, respectively, based on the priorities.
1 . A method, comprising:
receiving a plurality of payment denials for medical claims from a plurality of payors;
assigning, using an artificial intelligence engine, priorities to the plurality of payment denials, respectively; and
assigning, using the artificial intelligence engine, the plurality of payment denials to a plurality of agents responsible for obtaining payment approvals for the medical claims for which the payment denials have been received, respectively, based on the priorities.
2 . The method of claim 1 , wherein assigning, using the artificial intelligence engine, the priorities comprises:
assigning, using the artificial intelligence engine, the priorities to the plurality of payment denials, respectively, based on projected values associated with the plurality of payment denials, respectively.
3 . The method of claim 2 , further comprising:
determining, using the artificial intelligence engine, probabilities of obtaining payment approvals for the medical claims for which the payment denials have been received, respectively; and
estimating, using the artificial intelligence engine, payment amounts for the medical claims for which the payment denials have been received, respectively.
4 . The method of claim 3 , further comprising:
determining the projected values associated with the plurality of payment denials based on the probabilities of obtaining payment approvals that have been determined and the payment amounts that have been estimated, respectively.
5 . The method of claim 1 , wherein assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents comprises:
assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents based on the priorities and characteristics associated with each of the plurality of agents.
6 . The method of claim 5 , wherein the characteristics associated with each of the plurality of agents comprises one or more of a plurality of skillsets, an availability, and a location.
7 . The method of claim 6 , wherein each of the plurality of skillsets is associated with at least one of a plurality of claim adjustment reason codes used by the plurality of payors.
8 . The method of claim 6 , further comprising:
determining for one of the plurality of agents times taken for obtaining payment approvals for the medical claims that have been assigned to the one of the plurality of agents, respectively for different ones of the plurality of skillsets.
9 . The method of claim 6 , wherein the plurality of skillsets comprises a first skillset associated with provider credentialing, a second skillset associated with treatment pre-authorization, a third skillset associated with medical coding, a fourth skillset associated with payor plan eligibility, a fifth skillset associated with payor underpayment, a sixth skillset associated with documentation requests, a seventh high level general skillset, an eight medium level general skillset, and/or a ninth low level general skillset.
10 . The method of claim 6 , wherein the availability is based on a number of the plurality of payment denials assigned to the respective one of the plurality of agents.
11 . The method of claim 6 , wherein the location identifies a time zone for the respective one of the plurality of agents.
12 . A system, comprising:
a processor; and
a memory coupled to the processor and comprising computer readable program code embodied in the memory that is executable by the processor to perform operations comprising:
receiving a plurality of payment denials for medical claims from a plurality of payors; and
assigning, using an artificial intelligence engine, priorities to the plurality of payment denials, respectively;
assigning, using the artificial intelligence engine, the plurality of payment denials to a plurality of agents responsible for obtaining payment approvals for the medical claims for which the payment denials have been received, respectively, based on the priorities.
13 . The system of claim 12 , wherein assigning, using the artificial intelligence engine, the priorities comprises:
assigning, using the artificial intelligence engine, the priorities to the plurality of payment denials, respectively, based on projected values associated with the plurality of payment denials, respectively.
14 . The system of claim 13 , wherein the operations further comprise:
determining, using the artificial intelligence engine, probabilities of obtaining payment approvals for the medical claims for which the payment denials have been received, respectively; and
estimating, using the artificial intelligence engine, payment amounts for the medical claims for which the payment denials have been received, respectively.
15 . The system of claim 14 , wherein the operations further comprise:
determining the projected values associated with the plurality of payment denials based on the probabilities of obtaining payment approvals that have been determined and the payment amounts that have been estimated, respectively.
16 . The system of claim 12 , wherein assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents comprises:
assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents based on the priorities and characteristics associated with each of the plurality of agents.
17 . A computer program product, comprising:
a non-transitory computer readable storage medium comprising computer readable program code embodied in the medium that is executable by a processor to perform operations comprising:
receiving a plurality of payment denials for medical claims from a plurality of payors;
assigning, using an artificial intelligence engine, priorities to the plurality of payment denials, respectively; and
assigning, using the artificial intelligence engine, the plurality of payment denials to a plurality of agents responsible for obtaining payment approvals for the medical claims for which the payment denials have been received, respectively, based on the priorities.
18 . The computer program product of claim 17 , wherein assigning, using the artificial intelligence engine, the priorities comprises:
assigning, using the artificial intelligence engine, the priorities to the plurality of payment denials, respectively, based on projected values associated with the plurality of payment denials, respectively;
wherein the operations further comprise:
determining, using the artificial intelligence engine, probabilities of obtaining payment approvals for the medical claims for which the payment denials have been received, respectively; and
estimating, using the artificial intelligence engine, payment amounts for the medical claims for which the payment denials have been received, respectively.
19 . The computer program product of claim 18 , wherein the operations further comprise:
determining the projected values associated with the plurality of payment denials based on the probabilities of obtaining payment approvals that have been determined and the payment amounts that have been estimated, respectively.
20 . The computer program product of claim 17 , wherein assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents comprises:
assigning, using the artificial intelligence engine, the plurality of payment denials to the plurality of agents based on the priorities and characteristics associated with each of the plurality of agents.