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AI Machine Learning (ML) in RCM

        Artificial Intelligence (AI) IN RCM   
     MEASURe | MONITOR | MONETIZE

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Women Owned Business Certified Logo

Our
Approach

 

HUMAN CENTRIC AI:​

​P3 Quality™ is an Artificial Intelligence (AI) Tech company with specialities in AI in Revenue Cycle research, development, and issue resolution management. We focus on driving client success and efficiency:

  • Advancing Human In the Loop (HITL) Governance 

    • Building Frameworks 

    • Standardizing Broken Processes

 

​OUR CORE VALUES:  

  • People, Processes & Principles

    • Human Centric AI ​Solutions

​

AI SOLUTIONS FOR RCM RISK MITIGATION:

  • AI AuditME™ Product(s)

 

REDUCE AI DRIFT & HALLUCINATION RISKS:

  • Still seeing high volumes, errors, and issues with documentation, coding, and denials?

  • Rework consuming return on investment (ROI) dollars?

    • You have questions?  |  We have Answers!

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AI-FOCUSED AUDITS​​

Inspect, Detect, Diagnose, & Improve 

  • AI Model Data Drift & Hallucinations​

  • Automated Coding Validation Issues

  • Quality Assurance | Quality Control Inconsistencies

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ISSUE RESOLUTION WORKFLOWS:  â€‹â€‹

  • Revenue Integrity, HIM, CDI & RCM Functions

  • RCM Robotic Processing Automation (RPA)

    • AI Needs Assessment | AI Gap Analysis 

​​ â€‹â€‹â€‹â€‹

P3 QUALITY is a WBE (WBENC), nationally certified by the Women's Business Enterprise National Council and Georgia (SBSD) as a Certified Small Woman-Owned Business.

​

Our
Methodology

AI AUDIT METHODOLOGY:

Compliant, AccountableResponsible, and Ethical Use of AI:

​

​​​​NAIC-ALIGNED STANDARDS

  1. Governance 

  2. Transparency

  3. Accountability & Responsibility

  4. Data Quality, Privacy & Protections 

  5. Testing & Validation 

  6. Security & Risk Mitigation

  7. Third-Party BAA & Vendor Risks

  8. Consumer Protections

  9. Ongoing Audits, Monitoring & Maintenance​

 

WHAT IS HUMAN CENTRIC AI?

SMART COMPUTER TECHNOLOGY

Human-Centric AI is smart computer technology that works with people. It is a very helpful assistant.  But humans are allowed to make the final decisions.  

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HEALTH DEMOGRAPHICS VALIDATION​

  • Verify accuracy

  • Correct errors

  • Decide next steps ​

    • Review AI suggestions

    • Trust human-in-the-loop decisions 

​

QUALITY/COMPLIANCE AUDIT RISKS

  • AI flags the risk

    • Humans should confirm applicability​​

    • Humans should classify severity

    • Keenly focused on reducing and avoiding risks

​​

EXPLAINABILITY AND AN AUDIT OF DEFENSIBILITY STRATEGY

  • Human-centric AI should 

    • Show why the issue has been flagged

    • Link findings to

      • Policies/procedures 

      • Payer rules

      • Historical baselines

    • Identify AI-related inconsistencies

    • Improve confidence levels

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​​​​​​

AI | RCM | RPA AUTOMATION 

 

DOCUMENTATION AND CODING 

Inconsistent CDI Flag Errors

  • ​Upcoded/Undercoded E/M Levels​​​​

  • Incorrect Procedural Hierarchies 

  • Misassigned Chronic Conditions

​​​

AI ERRORS CREATE

  • Quality/Compliance Exposure

  • Payer Audit Risks

  • Ethical/Legal Implications 

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THIS STEMS FROM

  • AI Drift and Hallucinations​

MONITOR AI DRIFT & HALLUCINATIONS​​

AI Algorithm errors erode trust between patients, providers, and payers:

  • Coding Errors Increase

  • Providers Lose Confidence in Automated Coding Systems 

  • Patients Dispute Bills 

  • RCM Leaders Distrust Their AI Investment 

​​

MONETIZE KEY PERFORMANCE INDICATORS  (KPIs): 

  • Accuracy Variance (AI model output)

  • Coding/CDI Disagreement Rates

  • Claim Denial Spikes tied to AI-Generated logic

  • Charge Capture Changes > 10 YOY w/o Clinical Justification

  • DNFB Increase Linked to AI Inconsistencies

  • ​Unexpected MUE, CCI, HCC, or DRG shifts

  • Payer Rule Incompatibilities 

​​

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RCM ROBOTIC PROCESSING AUTOMATION (RPA) SERVICES
  • Eligibility Verifications 

  • Prior Authorizations

  • Clinical Documentation Integrity (CDI)

  • Charge Integrity 

  • AI Medical Coding 

  • AI Vendor Selection 

  • AI Needs Assessment

  • AI Project Oversight 

  • BAA & SLA Review 

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