health care, AI tools, AI in health care

Machinify was founded in 2016 to create an AI-based software platform that would reduce cost and waste in the multi-trillion-dollar health care claims process. Now it has a suite of three commercial applications to run on the platform.

The startup this week unveiled the trio of software offerings that automate the health care claims lifecycle, including authorizing requests, identifying potential issues with incoming claims, and addressing contract and payment policies.

Prasanna Ganesan, founder and CEO of Machinify, said in a statement that “there is an enormous opportunity to leverage AI to change the economics of health care,” adding that the company’s solutions “remove hundreds of millions of dollars in administrative costs from the health care system, benefiting not only payers, but providers and, most importantly, patients.”

The new software offerings – Machinify Auth, Machinify Audit, and Machinify Pay – come at a time of escalating health care costs in the United States. According to the company, health insurance companies pay out almost $4.5 trillion in reimbursement, a rate of about $13,400 per person. About $1 trillion of that is considered wasteful spending and about $500 billion of that waste come from administrative complexity and pricing failures, the vendor said.

Making the Process More Efficient

Insurance companies are looking for help to make the system more efficient and less costly, and Machinify is using AI and automation to address the problems. Four of the top 10 U.S. health insurance companies are under contract with the company and about 52 million people are covered by the vendor’s platform.

Through the platform, Machinify reviews $200 billion in medical claims every year. The AI engine that powers the cloud-based software uses such AI tools as natural language processing, optical character recognition, and large-language models and is trained on billions of claims and millions of medical records to learn medical coding.

Machinify’s Software

Machinify Auth automates the review of proposed medical treatments to ensure they’re appropriate and provides the authorization for proper reimbursement. It also speeds up the process, being able to provide an answer in real-time. If a doctor or other health care provider needs to intervene in the review, it can increase their productivity by as much as 800%.

For patients, it addresses the issue of delayed or abandoned care, which can be as high as 40%, according to the vendor, which also claims the software can protect again over- or under-treatment, delivers faster time to care, and makes it easier to see what is and what isn’t covered. For payers, the benefits can be a 10-times reduction in preauthorization costs, faster and more accurate decisions, and improve the patient’s experience and their relationship with the insurance company.

Machinify Audit leverage the AI training to automate the clinical review of medical claims, including finding potential clinical, coding, or billing issues on claims, analyzing medical records against clinical and coding guidelines, and ensure accurate payment. It also helps to prevent unnecessary treatments or procedures, and detect undiagnosed underlying conditions. It cuts in half the time needed to review claims and doubles review capacity, the vendor says.

Machinify Pay address everything around billing, including coding, contractual, and payment policies at wire speed to accurately price claims and automate corrections. The software automates 40% of recoveries with no human intervention for a top 10 U.S. payer and uncovered $125 million in additional recoveries beyond the time savings.

AI and Health Care

As with other industries, AI is expected to have a significant presence in the health care industry, with global AI spending in the field expected to grow from $11 billion in 2021 to almost $188 billion by 2030.

“That massive increase means we will likely continue to see considerable changes in how medical providers, hospitals, pharmaceutical and biotechnology companies, and others in the health care industry operate,” IBM wrote last year.

Machinify is looking to gain more traction in an increasingly crowded field of vendors that range from the established – like Google’s DeepMind business – to more specialized companies, like Gradient AI and Shift Technology, a company four years older than Machinify.

While such companies tout the cost and time savings and other efficiencies their products deliver to the health insurance field, some are complaining that insurers are using AI to wrongly deny coverage. For example, lawsuits have been filed against the likes of UnitedHealth and Humana, both of whom used an AI model called nH Predict and created by NaviHealth. Both face accusations of wrongly denying medical care.

The American Medical Association (AMA) last year called for greater government oversight as health insurers’ use of AI for patient claim and prior-authorization decisions grows.

“The use of AI in prior authorization can be a positive step toward reducing the use of valuable practice resources to conduct these manual, time-consuming processes,” AMA Trustee Marilyn Heine said in a statement. “But AI is not a silver bullet. As health insurance companies increasingly rely on AI as a more economical way to conduct prior-authorization reviews, the sheer volume of prior-authorization requirements continues to be a massive burden for physicians and creates significant barriers to care for patients.”

Heine added that “the bottom line remains the same: We must reduce the number of things that are subject to prior authorization.”