Artificial Intelligence as a Tool to Mitigate Administrative Burden, Optimize Billing, Reduce Insurance and Credentialing-Related Expenses, and Improve Quality Assurance within Healthcare Systems.

Abstract

Despite spending $4.3 trillion annually in healthcare with $3.4 trillion ($10,193 per capita) attributed to care delivery, the United States (U.S.) still experiences the worst health outcomes among high-income countries. Administrative costs are the second largest contributor with $353 billion ($1,055 per capita) spent annually. Addressing clinical and administrative fragmentation can reduce annual costs by up to $265 million and increase healthcare productivity, both of which contribute to care delivery that is necessary, effective, equitable, and fiscally responsible. In the advent of electronic health records (EHRs), big data, and artificial intelligence (AI), there is an unprecedented opportunity to leverage these tools to drive meaningful improvements in high-value care delivery and reduce both clinical/non-clinical administrative costs. Physician engagement to develop comprehensive musculoskeletal data management systems is a critical precursor for subsequent application of AI analytics. Incorporation of AI tools developed from these data systems both within-organizations and seismically across the healthcare system can: (1) promote transparency via payer/provider data-sharing platforms; (2) automate routine, evidence-based care to reduce ineffective, inefficient, and inconsistent medical decisions; (3) align incentives of key stakeholders by incorporating epidemiological informatic insights and individual patient-centered value quantification to inform physician-patient decision-making; (4) mitigate care delays from prior authorization (PA) and claims processing via centralized digital-claims clearinghouses; (5) guide payment model evolution to accurately and transparently reflect costs of care for patients with different risk profiles (6) harmonize quality control reporting for comparability; (7) simplify and standardize PA processes to reduce administrative complexity; and (8) automate non-clinical repetitive work (i.e. credentialing, quality assurance, etc.). Adoption of these tools can eliminate $168 billion in annual administrative costs. While no single solution will perfectly transform healthcare, the strategic and responsible use of AI technologies could lead to transcendent improvements in delivery of healthcare that is patient-centered, equitable, efficient, and fiscally responsible.