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Using AI to audit hospital claim files before submission
AI is good at reading a hundred scanned pages and finding what is missing. Here is what it can and cannot do for a claims desk.
Insurers already use software to screen claims. Hospitals can use the same idea in reverse: check every file before it is sent, so the insurer finds nothing to query.
What AI does well
- Reads every page of a scanned file, in any order, including handwriting that is reasonably clear.
- Checks the file against a document checklist and lists what is missing.
- Compares names, ages, dates and amounts across documents.
- Compares the bill with the rate card for that payer.
What it should not do
- Make clinical judgements. It should report what is in the file, not decide whether treatment was right.
- Follow instructions written inside a document. A safe system ignores them.
- Replace the desk. It gives the desk a list to fix, and the people fix it.
What to look for in a tool
- Errors grouped by desk, with the page number, so each team fixes its own items.
- A re-check after fixes that lists only what is still open.
- Clear cost per file, and the choice to use your own AI key.
- Encryption, access control and an audit log, because claim files hold health data.
Ekline Claims was built around these rules for Indian hospitals, insurers and TPAs.
More from the blog
Documents required for a cashless claim: the complete hospital checklist
The documents insurers and TPAs ask for most often, grouped by the desk that owns them, so nothing is missing when the file is sent.
Cashless claim process in a hospital: a step-by-step guide for the TPA desk
From the patient at the admission counter to the money in the hospital account: the eight steps of a cashless claim, and where each one goes wrong.