Availity Launches Groundbreaking AI Claims Denial Prediction Tool, Powered by Anomaly Insights

Availity, the nation’s largest real-time health information network, announced the launch of Predictive Editing, the latest feature of the company’s robust end-to-end revenue cycle management platform, Availity Essentials Pro™.

Predictive Editing’s engine, powered by artificial intelligence (AI), helps prevent claims denials by analyzing extensive claims data to identify potential denials prior to submission at the front-end of the provider’s submission workflow, allowing for timely corrections and smoother adjudication.

In a recent proof-of-concept study of more than 100 million claims from two large health systems, the Predictive Editing tool demonstrated impressive results, flagging more than $828 million denials with 97% precision.

How Predictive Editing Works

The Predictive Editing tool analyzes millions of historical claims, comparing them to remittance data to detect payment patterns. These patterns are then used to flag new claims likely to be denied by the health plan prior to submission for quick and easy correction.

Built and trained on a database of more than 3 billion medical and pharmacy claims, Predictive Editing’s AI engine is tuned to each provider’s payment environment and payers’ adjudication rules, creating and applying new edits in response to changing conditions. Additionally, Availity’s AI-powered tool:

• Automates upfront edits, eliminating manual retrospective analysis of denied claims
• Addresses complex payer-specific edit scenarios far beyond the capabilities of the market’s traditional edit engines
• Complements most editing tools and processes, extending their effectiveness while reducing administrative effort to maintain manual rules and edits.

“Availity’s Predictive Editing tool works in real-time within the workflow and it can review each claim and permutation of the claim as its being created, generating predictions with virtually no latency and returning guidance via API,” said Linda Perryclear, Senior Director of Product Management for Availity Essentials Pro. “With Predictive Editing, providers have a tool that drives a more seamless payment process for providers nationwide through Availity Essentials Pro.”

Robust AI Engine

The AI-engine that powers Predictive Editing was developed by and is being deployed in partnership with Anomaly Insights, a leading provider of Artificial Intelligence/Machine Learning (AI/ML) solutions for health payment intelligence.

“Claims adjudication has gotten more complex, and, as a result, the entire system is being bogged down by denials and the cost associated with managing them,” said Mike Desjadon, Anomaly CEO. “Our partnership with Availity provides a unique opportunity to bring advanced AI/ML capabilities directly to providers and payers to eliminate cost and waste.”

• Learn more about Predictive Editing here.
• Learn more about Availity Essentials Pro here.

About Availity

Availity is the trusted partner for organizations seeking to realize the greatest value from clinical, administrative, and financial data. Positioned at the nexus of provider, health plan, and consumer health information, Availity develops scalable, innovative solutions for healthcare data acquisition, standardization, transparency, automation, and exchange among health plans, providers, and technology partners. As one of the nation's largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment.

For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn and X.

About Anomaly Insights

Anomaly Insights is a leading provider of Artificial Intelligence (AI) and Machine Learning (ML) products to improve healthcare payment performance. At the core of Anomaly’s capability is its proprietary AI/ML engine - Smart Response. Smart Response directly integrates anywhere into the payment flow from scheduling through billing and provides real-time predictions on whether a clinical interaction will be paid or denied and monitors millions of transactions to surface previously hidden payment and denial patterns and emerging trends that can be acted on. Learn more at www.findanomaly.com.

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