A proprietary Artificial Intelligence (AI) tool, which continuously analyzes encounter and audit data across all eValuator clients, enabled the creation of new rules, enhancements to existing rules, and tailored client insights. These AI-driven rules resulted in annualized financial impact of $11.3M within six weeks.
Beyond Human Cognition: AI & eValuator™
At the core of eValuator is its AI-enhanced rules engine, which leverages global or custom rules to identify encounters for pre-bill review. Streamline’s proprietary AI tool reviews every encounter audited by eValuator users nationwide, revealing complex patterns and novel insights to create high-impact rules that expand the impact and possibilities of the existing solution.
The Process
The process initiates with the analysis of all audited encounters, grouping similar changes and coding together into clusters. These clusters are then reviewed by the eValuator Rules Team to verify the potential for creating or improving a rule that would identify such encounters in the future. Rules generated or enhanced from the AI analysis undergo testing and implementation, ultimately leading to enhanced productivity, revenue, and coding integrity for our clients.
Three Use Cases: Real Examples
New Rules
A newly formulated rule, drawn from AI insights, identifies documented or supported MCC conditions, including causal infection and/or associated major organ dysfunction in admissions for systemic infection/sepsis. This rule has generated an incremental $230K in financial impact across our client base thus far.
Enhanced Rules
AI identified an opportunity to enhance the specificity of a global rule for stroke patients. Adding diagnosis codes to the original rule created a smarter rule that improved auditor efficiency by reducing false-positives, increased reimbursement from $130K to $360K and improved the DRG change rate from 4% to 23%.
Tailored Client Insights
eValuator clients have the flexibility to enable or disable rules at their discretion. For a client who had deactivated a rule related to respiratory failure, AI analysis revealed significant potential for improving revenue and coding integrity by reactivating the rule. Each flagged encounter presented an opportunity to raise reimbursements by over $1,000 per case.
What’s Next?
Our AI tool continuously refines and innovates, generating new rules, enhancing existing ones, and revealing tailored insights based on each client’s distinct revenue cycle environment. As we aggregate more encounter and audit data from our clients, the potential for AI-driven rules will exponentially expand. But we aren’t stopping there!
Our eValuator solution’s AI has the potential to employ AI insights to forecast the chance of a denial and the probability of winning an appeal. This capability will revolutionize the provider-payor relationship dynamics, empowering providers to take a proactive stance and assertively engage with payors.
