AI is transforming how healthcare payers protect their dollars. One of the best places to see this impact is in payment integrity. This is where health plans can use AI to prevent fraud, waste, abuse, and errors (FWAE) before claims are paid. It’s fast, effective, and measurable.
Where AI Works Best Right Now
If you’re just starting with AI, here are three proven ways to use it in payment integrity:
- Find risky claims before payment
AI models can detect coding and provider anomalies that look suspicious. This helps stop bad claims early, saving both time and money. - Help SIU teams move faster
Investigators deal with too many systems and manual work. AI can cut down steps, suggest next actions, and show the most relevant data, improving how cases are handled. - Simulate fraud reviews
When there aren’t enough fraud specialists, AI can predict which claims are worth reviewing. This helps teams focus on high-impact work.
What’s Next: Bigger Gains With More Innovation
Some health plans are going further with advanced use cases:
- AI that writes claim edits from policy documents
AI can read and convert payer rules into real-time editing logic, speeding up the process. - AI agents that assist or run reviews
These tools can reduce manual reviews and shift work to the prepay side, but they must be used carefully to avoid errors or negative member impact.
At HCFS, we help plans adopt both quick wins and future-ready tools with our modular, AI-powered platform.
3 Smart Steps to Start
- Solve a real problem
Use AI to reduce waste, speed up reviews, or spot fraud—whatever matters most to your team. - Track results clearly
Measure time saved, dollars recovered, or improved investigator output. We help you do this from day one. - Start small, grow fast
Prove value quickly, then scale up. Our tools are designed to grow with you.
Ready to See Results?
HCFS has helped payers find and stop FWAE for over a decade using AI. We understand your challenges because our tools are built for them.
Let’s talk about how we can help you get started, or go further, with AI in payment integrity.