Intelligent Claim Denial Solution for Healthcare

Healthcare organizations face substantial revenue loss due to frequent and preventable claim denials. Hexaware’s Intelligent Claim Denial Solution for Healthcare leverages machine learning models and Microsoft Azure LLMs to predict, prevent, and reduce denials before they occur.

The solution delivers clear, actionable insights that streamline workflows, improve clean claim rates, and enhance revenue realization enabling healthcare organizations to operate with greater efficiency, accuracy, and financial confidence.

Pain Points of RCM:

• 10–15% of claims are denied initially, causing payment delays and revenue loss
• 60–65% of denials result from preventable upstream errors, impacting financial performance
• Providers experience a yearly loss of 3-5% in net patient revenue because of denials and write-offs
• Lack of real-time visibility hinders leadership’s ability to manage denial risks and revenue impact.

Features:

• Analytic dashboards that display critical claim and denial metrics to support informed decision-making
• Machine learning–driven risk categorization to prioritize claims based on predicted denial likelihood
• AI-powered pre-submission insights that identify operational risks and documentation gaps
• Conversational AI interface enabling trend analysis and automated report generation

Business Benefits

• Reduces preventable claim denials by 35% and improves clean claim rates by 10% for faster revenue recovery.
• Enhance productivity by 30% and decreases appeals and rework by 25%, lowering operational expenses.
• Lowers cost to collect and boosts staff satisfaction through streamlined, automated workflows.

Outcome:
Tailored Proof of Concept (PoC) based on user requirements, with scope for full-scale solution implementation. The engagement also offers consultative guidance for use case discovery, prioritization, and roadmap planning.

Key Azure Services:
Azure Foundry, Azure OpenAI, Azure AI Search, Azure Cosmos DB, Azure Monitor, Azure Kubernetes Service, Azure Firewall, Azure App Service

Price depends on the scope and the solution being implemented