Oracle Health has officially announced the launch of its strategy to strengthen the collaboration between healthcare providers and payers.
According to certain reports, the company will introduce, as a part of the whole package, 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.
More on the same would reveal how these applications and AI agents aim to significantly reduce administrative costs, and at the same time, improve value-based care initiatives all for the purpose of maximizing care quality and optimizing resource allocation.
To understand the significance of such a development, we must take into account how administrative costs related to healthcare billing and insurance are estimated at approximately $200 billion annually. We say so because, despite continued efforts towards electronic exchanges and regulatory interventions, these unsustainable costs continue to rise largely due to complexity of medical and financial processing rules and rapidly evolving payment models.
Against that, Oracle Health’s suite of AI-fueled applications arrive on the scene bearing an ability to address several of these fundamental challenges to navigate a wide set of payer-specific business rules. The idea here is to accelerate processing on both sides, while simultaneously securing timely payer responses and decisions to better meet patient care needs.
More on the same would reveal how 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 a complimentary ability to embed AI agents that are built to be payer-rules aware, providers can seamlessly apply payer-specific rules during the patient workflow to increase clean submissions at every stage of the process. Such a mechanism, like you can guess, really goes the distance to increase submission accuracy to significantly reduce the time spent on documentation, helping facilitate faster claims processing.
On the other hand, the collaboration between agents and the payer rules can also help reduce payer claims inquiries and denials so to collectively save hundreds of millions of dollars in administrative costs.
Talk about the whole value proposition on a slightly deeper level, we begin from the point of prior authorization.
This translates to how 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. The idea here is to eliminate the faxes, requests for more information, and phone call follow ups rampant throughout the industry today. .
Next up, we have the prospect of Eligibility and Coverage Determination. You see, Oracle Health Eligibility Verification Agent can help providers accurately determine eligibility information, as well as avail detailed coverage information required to provide full price transparency to patients at the point of care delivery to avoid “surprise billing.”
Leveraging full member benefit information to the AI agent, payers can even help providers recommend treatments, medications, service locations, and medical programs that are covered under the patient’s insurance plan.
Another detail worth a mention is rooted in Medical Coding, where Oracle’s agentic technology could very well work in parallel with a documentation agent to autonomously generate all medical codes – condition codes, diagnosis & DRG codes, for all types of clinical settings.
Joining that would be an assortment of Autonomous Reimbursement Agents, capable of installing payer-specific codes and modifiers at every possible touchpoint. Payers can also deploy their coding guidelines to let the agent pre-apply to reduce coding errors.
Rounding up highlights would be potential for enhanced claim processing. In that respect, Oracle Health Charge Agent, Oracle Health Contract Agent, and Oracle Health Claims Agent can also work together to support accurate capture of charges and compliant submission of claims.
“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.”