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September 9, 2016
09 Sep 2016

Artificial Intelligence “Servant” Dramatically Improves Revenue Cycle by Reducing Adjudication

MiddleGate www.middlegateinc.com provides cloud based, predictive, machine intelligent solutions for the healthcare industry.  The “servant” is designed to review an unlimited amount of data from every perspective, make accurate predictions, and offer your best suggested actions…especially as things change.

Example Use Case #1:  Monitor all electronic data for fraud, waste, and abuse.  MiddleGate has monitored the daily activity for health practices, establishing the normal behaviors of each claim, provider, and patient.  When any anomaly occurs, we find it, alert the owner, and suggest the best course of action forward.  To date, MiddleGate has found patient fraud, physician over billing, physician fraud, and medical billing fraud.

Example Use Case #2:  Adjudication Reduction for revenue cycle management.  A Midwest RCM firm, representing almost 100 provider groups and $500 Million in annual claims was frustrated with the effort and cost of adjudication.  MiddleGate analyzed each of the past 10 Million claims from every angle and now suggests which claims will make the most money for the least effort every day.

MiddleGate predicts:

  • Which claims only need an appeal letter to be paid.  These claims do not need human intervention any more.  The machine grabs the right appeal letter, sends to the right payer to be paid without ANY cost of adjudication.
  • Which claims are a “green light” (high dollar recovery and very low effort to work this appeal or denial) BEFORE the cost of adjudication.
  • Which claims are a “yellow light” (small dollar and a small effort to work this appeal or denial) BEFORE the cost of adjudication.
  • Which claims are a “red light” (low dollar and a high effort to work this appeal or denial) BEFORE the cost of adjudication.
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