Oracle Plans To Introduce A Comprehensive New Suite Of AI-Powered Applications To Increase Automation In Prior Authorizations, Reduce Claims Denials, And Enhance Care Coordination Between Payers And Providers

Solving a two-hundred-billion-dollar problem with AI

Administrative costs related to healthcare billing and insurance are estimated at approximately $200 billion annually. Despite continued efforts toward electronic exchanges and regulatory interventions, these unsustainable costs continue to rise, in large part due to complexity of medical and financial processing rules and rapidly evolving payment models. Currently, rules and models are time-consuming and inefficient for providers to follow and adopt, and their reliance on manual processes makes them prone to costly errors. Oracle Health's suite of AI-fueled applications is designed to address several of these fundamental challenges to navigate a wide set of payer-specific business rules. This is expected to help speed up processing on both sides, while securing timely payer responses and decisions to better meet patient care needs.

"Oracle Health is working to solve long standing problems in healthcare with AI-powered solutions that simplify transactions between payers and providers," said Seema Verma, executive vice president and general manager, Oracle Health and Life Sciences. "Our offerings can help minimize administrative complexity and waste to improve accuracy and reduce costs for both parties. With these capabilities, providers can better navigate payer-specific coverage, medical necessity, and billing rules while enabling payers to lower administrative workloads by receiving more accurate claims from the start."

Reducing friction between payers and providers 

The Oracle Health suite of clinically integrated, AI-based applications and AI agents will be designed to target large friction points between payers and providers, including prior authorization, eligibility verification, coverage determination, medical coding, claims processing, and denial management. With the ability to embed AI agents that are built to be payer-rules aware, providers can apply payer-specific rules during the patient workflow to help increase clean submissions at every stage of the process. This can help increase submission accuracy to significantly reduce the time spent on documentation and help facilitate faster claims processing. At the same time, payer-side claims processing can be dramatically simplified and achieved in near real-time. These agents working with the payer rules can also help reduce payer claims inquiries and denials, potentially saving the entire industry hundreds of millions of dollars in administrative costs.

Oracle's initial offerings are planned to focus on simplifying and reducing the cost of the following processes:

• Prior Authorization: Oracle Health Prior Authorization Agent can discover the prior authorization need, retrieve the documentation requirements, automatically prefill information for review, and submit the prior authorization request to payers digitally. This has the power to eliminate the faxes, requests for more information, and phone call follow ups prevalent in the industry today. Payers are anticipated to be able to further enhance this process by providing comprehensive medical necessity criteria which provider AI agents can pre-apply to better avoid requests not clinically indicated. 
  
  
  
   
• Eligibility and Coverage Determination: Oracle Health Eligibility Verification Agent can help providers accurately determine eligibility information while also retrieving detailed coverage information required to provide full price transparency to patients at the point of care delivery to avoid "surprise billing." Payers, by providing full member benefit information to the AI agent, are expected to be able to help providers recommend treatments, medications, service locations, and medical programs that are covered under the patient's insurance plan. Payers and providers can both benefit from accurate billing and ideally be able to reduce costly third-party data exchange fees with direct connectivity.
  
  
  
   
• Medical Coding: Oracle Health Coding Agent is designed to work in parallel with a documentation agent to autonomously generate all medical codes – condition codes, diagnosis & DRG codes – for all types of clinical settings. Autonomous reimbursement agents are designed to further add payer-specific codes and modifiers where possible. Payers are anticipated to be able to take advantage of these agents by providing their coding guidelines that the agent can pre-apply to reduce coding errors.
  
  
  
   
• Claims Processing: Oracle Health Charge Agent, Oracle Health Contract Agent, and Oracle Health Claims Agent, while each designed to perform a piece of the provider reimbursement workflow, can work together to support accurate capture of charges and compliant submission of claims. Payers can take advantage of the AI agent capabilities and 'left shift' their grouping and billing rules into the provider workflow, which is expected to result in the generation of a clean claim.

Supporting value-based care

Health systems using Oracle Health Data Intelligence can leverage payer-provided insights to close more care gaps and improve patient care quality and value-based care contract performance. Oracle Health plans to deliver a new care and risk coding gaps capability that can enhance payer and provider collaboration by integrating insights from payers for risk coding and quality care gaps into provider workflows at the point of care. It is expected that payers will be enabled to connect via a single connection point to link with any provider utilizing Oracle Health Data Intelligence, regardless of the EHR, and be able to share risk coding and care gaps for their enrolled members, fostering a simplified process as they help providers improve HEDIS and pay-for-performance outcomes.

To accelerate data exchange between payers and providers, the planned products are intended to integrate with Oracle Health Clinical Data Exchange, which is designed to replace laborious manual transmission of medical records with a centralized network that can reduce administrative time and costs, all while retaining tight control over data security. Recent updates to the solution enable payers to retrieve encounter data directly from the EHR, validate eligibility, surface coding and quality gaps directly in provider workflows, and leverage event-driven updates across multiple phases.