GEN AI ENABLED RCM OPERATIONS
Revenue Cycle Management (RCM) is the financial heartbeat of any healthcare system. Yet, traditional RCM operations are slow, fragmented, and heavily manual—resulting in delays, denials, and revenue leakage.
Value Health transforms RCM by infusing it with Gen AI and intelligent automation—reducing human dependency while increasing accuracy, efficiency, and compliance. From intake to claim submission, denial resolution to AR tracking, we build smarter workflows that unlock revenue faster and lower operational costs.
Whether you’re a provider, specialty pharmacy, or hub, our Gen AI–powered RCM solutions offer end-to-end automation with human-in-the-loop oversight—ensuring both speed and accuracy without compromising compliance.
Key Challenges in Traditional RCM
- Manual data entry and fragmented intake processes
- Delays in benefit verification and prior authorizations
- High claim denial rates and delayed reimbursements
- Lack of real-time visibility into claim statuses and AR
- Rising operational costs from seasonal hiring and burnout
- Compliance risks due to fragmented processes and human error
Tangible Benefits with Gen AI-Powered RCM
| Challenge | Our Solution | Measurable Impact |
|---|---|---|
| Manual verification delays | Gen AI-powered eBV & eligibility automation | 3X faster intake & coverage checks |
| High denial rates | AI-driven pre-claim audits & auto-coding | 20–25% reduction in denials |
| Staffing spikes during volume surges | Scalable offshore + AI agent model | 40–50% cost savings |
| Administrative burnout | Automation of routine tasks | 89% higher staff satisfaction |
| Limited AR visibility | Real-time analytics dashboards | 25–30% reduction in aged AR |
| Complex payer compliance | HIPAA & payer-compliant workflows | Zero compliance breaches |
How we do it
We apply Agentic AI + automation + offshore resilience to every step in the RCM value chain
Data Intake & Triaging
- OCR + NLP-driven extraction of patient, payer, and coverage details from intake forms, insurance cards, and EOBs.
- Automated identification of missing or duplicate information.
Smart Benefit Verification (eBV)
- Gen AI agents instantly verify benefits through payer portals.
- Summarized coverage insights shared with billing teams & patients.
- Seamless escalation of restricted or uncovered cases to prior authorization.
Automated Medical Coding & Claim Generation
- Auto-suggests ICD-10/HCPCS codes based on clinical data.
- Scrubs claims for compliance before submission.
- Drafts appeals for denials with contextual insights.
Real-Time Analytics & Risk Monitoring
- Dashboards showing aged AR, clean claim rates, denial patterns, and collections by payer.
- Predictive alerts to address payment risks before they impact revenue.
24/7 AI + Human Support
- Offshore and onshore teams collaborate with AI agents to deliver round-the-clock coverage.
- Personalized engagement with patients and providers via chat, email, and SMS.
Compliance First
- All processes built with HIPAA compliance, payer privacy standards, and blockchain-secured data trails.
Case Study
Client Overview
A large U.S.-based outpatient provider network operating across 100+ clinics, offering primary and specialty care services. The organization was facing operational bottlenecks in revenue cycle management (RCM), particularly around insurance eligibility verification and claims processing.
Key Challenges
- Manual eligibility checks across multiple payer portals delayed patient intake.
- High claim denial rates (~15%) due to missed or inaccurate eligibility validation.
- Revenue recognition delays with Accounts Receivable (AR) cycles stretching beyond 45 days.
- Front-desk teams spent excessive time on repetitive verification tasks, impacting productivity.
Our Solution
Value Health implemented a Gen AI–powered eligibility verification engine that automated payer data extraction, real-time eligibility checks, and denial risk prediction. The solution integrated with their existing Electronic Health Record (EHR) and billing systems to streamline eligibility workflows.
Solution Highlights
- Gen AI interpreted payer responses (both API and document-based) and auto-verified coverage details.
- Automated detection of missing or conflicting insurance information.
- Real-time dashboards gave staff visibility into patient eligibility before the visit.
- Pre-submission denial risk scoring enabled proactive resolution.
“Schedule a consultation and begin your business transformation today”
