Automating Documentation for Medical Claims Submission

CLIENT

Medical Company

INDUSTRY

Healthcare

SERVICE

Gen AI

The Challenge

A medical office needed to reduce the number of claims sent back to Medical Assistants for corrections and updates to medical documentation required for successful claim approval. The Head of Revenue Cycle Management (RCM) identified that their staff was overloaded with daily manual reviews, affecting the promptness of claims reimbursements for completed work.

Before consulting with Sphere, the company considered several options:

  • Providing additional administrative training for Medical Assistants
  • Hiring additional staff for post-visit medical documentation review
  • Adding additional Medical Assistant review steps into the clinical workflow  to ensure documentation completeness

The Solution

To optimize the medical practice’s insurance claims process, Sphere implemented a structured approach that involved three key phases: Analysis and Standardization, Solution Design, and Implementation and Validation. Each phase played a crucial role in enhancing the efficiency and accuracy of claims processing, seamlessly integrating advanced GenAI technology into the practice’s existing workflow.

Analysis and Standartization

Sphere began by conducting a thorough analysis of the medical practice’s workflow and their existing insurance claim requirements needed for successful claims processing. This phase involved a detailed examination of the various types of claims, the specific data points required for each claim type, and the common reasons for claim rejections or delays. Sphere’s team worked closely with the medical practice’s staff to standardize these requirements, ensuring a consistent and clear set of criteria for medical documentation.

Once the claim requirements were standardized, Sphere moved on to identifying the optimal points within the workflow where an automated review would be most effective. By pinpointing the stages where errors or omissions were most likely to occur, Sphere was able to determine where a generative AI case file review could provide the greatest impact.

The goal was to develop a GenAI-based validation service that could seamlessly integrate into the clinic’s existing AdvancedMD EMR system workflows. This required designing a solution that could work in real-time, offering immediate feedback to Medical Assistants as they entered medical documentation. 

Sphere also focused on ensuring that the integration of this new service would not disrupt the clinic’s existing workflow. This involved designing the system to be user-friendly and intuitive, minimizing the learning curve for Medical Assistants and other staff members. By providing real-time validation with the existing EMR data, Sphere aimed to streamline the documentation process, reduce the need for manual reviews, and ultimately improve the promptness and accuracy of claims reimbursements.
Solution Design

The Sphere solution design involved a comprehensive GenAI-based validation service aimed at providing real-time status updates to Medical Assistants regarding the completeness of medical documentation from a claims processing perspective. This advanced solution was tailored to meet the specific needs of the medical practice and the insurance companies claim requirements, ensuring seamless integration into their workflow without causing operational disruptions.

As part of the Solution’s Design, Sphere outlined the necessary technical components and infrastructure required. This included the development of sophisticated algorithms capable of understanding and analyzing medical documentation, as well as the integration of these algorithms into the clinic’s existing AdvancedMD EMR system. Sphere also ensured that the system’s interface was user-friendly, allowing Medical Assistants to easily interpret and act on the validation feedback.
Implementation and Validation

The GenAI-based service was designed to automatically check for completeness and accuracy based on the standardized claim requirements, alerting Medical Assistants to any missing information that needed to be addressed for the claim to be successfully processed. Sphere developed and implemented the innovative solution to streamline the real-time review of medical documentation. Medical Assistants were informed at the time of entry if additional information was needed, reducing the likelihood of cases being sent back for further information.

Sphere conducted thorough testing to ensure the solution met all requirements. This extensive validation process was crucial to ensuring the solution’s accuracy and reliability. Sphere also invested in training in-house staff on the new systems and processes, ensuring they were well-prepared to manage the solution independently once fully operational. Sphere then transitioned the management of the solution to these in-house teams, equipping them with the necessary tools and knowledge for ongoing operation.

The Result

Sphere’s custom-made solution significantly reduced the number of corrections required after initial case submission. Additionally, the RCM team saw a notable reduction in fees associated with manual correction and resubmission of rejected claims by their contracted 3rd party vendor, attributed to the overall completeness and thoroughness of the real-time medical documentation review service.

Sphere’s expertise in GenAI and automation directly supported the company’s goals, providing a solution that their in-house team could not achieve without compromising their objectives. Leveraging the latest technological advancements, We effectively addressed the company’s challenges and delivered significant, quantifiable results.

Key Achievements

65% Reduction in Documentation Rework

Cases sent back to Medical Assistants for additional documentation before claim submission decreased by 65%, streamlining the workflow.
20% Faster Reimbursement

The average time for case reimbursement was reduced by 20%, accelerating the revenue cycle.
35% Decrease in Outstanding Accounts Receivable

The practice experienced a 35% reduction in daily outstanding accounts receivable (AR), significantly improving financial health.
Reduction in Correction Fees

The RCM team experienced a significant reduction in fees related to manual claim corrections, thanks to Sphere’s real-time documentation review service.