From Pay-and-Chase to Proactive: AI and Payment Integrity

Driven by higher use, increasing pharmacy costs, declining medical loss ratio rebates, and policy shifts, health insurance industry profit margins have narrowed even as annual healthcare spending rises. AI can help find savings by reducing medical and administrative expenses and targeting fraud and waste.

This industry outlook report will examine the current state of AI adoption in payment integrity programs across U.S. healthcare payers. As payers embed automation, machine learning, and generative and agentic AI across PI workflows, they can process complex claims with unprecedented speed and accuracy, at scale. Highlights include:

• Four types of AI that can be applied in payment integrity and how these technologies are reshaping PI workflows.
• Advice from industry experts on how AI can power the shift from reactive “pay and chase” PI approaches to proactive prevention of improper payments.
• Actionable steps that can help payers progress from AI experimentation to implementation.​​

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