October 30, 2023

7 Potential Applications for Artificial Intelligence in Workers’ Comp Medical Programs

By Healthesystems

Artificial Intelligence (AI) technology is advancing rapidly, with new applications being discovered every day for the medical aspects of claims and workers’ compensation claims management.

The benefits of AI in healthcare that have the potential to positively impact workers’ comp include reliably accurate diagnostics, better informed clinical decision support, improved medication management, expanded remote care, and higher levels of personalization and efficiency. The impact of these, either individually or in combination, could be life changing for injured workers and a game changer for workers’ comp payers.

In addition to delivering on the promise of better care, here are 7 ways AI may benefit workers’ compensation medical care programs:

  1. Automate claims processing: Learning from previous claims data, AI can sort claims according to levels of need, automatically processing the routine claims and routing the small percentage that need claims professional attention.

  2. Classify claims: AI can help to accurately classify injuries by analyzing lines of billing codes to ferret out the primary diagnosis for each claim, which can then be categorized and stored in a database for future intelligence. AI can also extract other information, such as codes for comorbidities, to identify health risks and cost drivers.

  3. Identify outliers: By learning from large data sets, AI can identify outliers beyond cost, including unusual courses of treatment, drug regimens, or duration of therapy when compared to similar injuries and patient characteristics.

  4. Select providers: Predictive models can be used to identify top performers based on relevant and statistically significant performance indicators for each claim’s individual characteristics.

  5. Predict risk and enable intervention: AI can detect when a claim is moving out of the expected cost range and send alerts as soon as a deviation from anticipated trajectory occurs to allow early intervention and prevent further escalation.

  6. Improve fraud detection: AI can scrutinize claims at a greater level of detail to identify hidden indicators of fraud, waste, and abuse.

  7. Prevent litigation: AI algorithms can predict the likelihood of litigation by analyzing and detecting patterns in past claims. At-risk claims can immediately be tagged and routed for special processing to avoid legal issues.

For more information on AI in healthcare and workers’ comp, read our article in RxInformer magazine.

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