RPA and AI Services | Business Support & AI Services in California

Prior Authorization / Pre Certification uses RISARC proven AI and RPA technology to first determine if the scheduled procedure requires prior authorization. If prior authorization is required, RPA and AI technology access the payer portal and enter the required information.

Proven Benefits

Prior Authorization automation solution takes the manual process out of submitting and tracking prior authorizations.
Prior Authorization can be automated with over 95% of big payers.
Approved or denied prior authorization information is automatically entered into the electronic medical record or system customer designates.
Prior Authorizations that need follow-up, i.e., peer to peer review/discussion, can be added to customer worklist or included into the RISARC “one stop shop” solution for prior authorizations.

Eligibility Verification is designed to reduce denials on the front end through the automation of verification of eligibility checks that ensure the correct date of service is captured, insurance is current, and it is the right patient. Any changes or updates are entered into the electronic medical record or system customer designates.

Proven Benefits

Automated eligibility checks that are done right before claim is submitted, eliminating the need for rework
Improves the claims reimbursement timeline

Medical Coding workflow is built on the RISARC “true” Artificial Intelligence and Robotic Processing Automation. Coding is totally automated, and feedback is sent to the provider to help improve their level of specificity and accuracy.

Proven Benefits

Claims are coded 24/7, which eliminates the coding backlog for claims that are ready for coding
Claims are coded accurately and at the highest level of specificity
The need for manual coding and submission of the professional claim is eliminated
After coding, all claims must pass the Artificial Intelligence test for completeness, highest level of accuracy and specificity for clean claims and first pass rate. This ensures that claims denial rate decreases.
Claims are tracked from submission to paid by payer
Continuous revenue expected collections monitoring based on payer agreement of submitted claims. Short pays are automatically reviewed and/or resubmitted
Provider clinical documentation improvement opportunities are automated and sent to provider as feedback and reporting
Charges are automatically cultivated to ensure compliance with billing rules for the payer

Denials Management workflow provides an automated solution to gathering the required data/documents to identify real-time trends and analytics for preventative actions. Denial trending data is used to work with payors on resolution and to provide feedback to provider which includes analytics by payor, by specialty, by physician, top denial reasons and high dollar patients. Underpaid or overpaid claims are also identified for resolution.

Proven Benefits

Automation of the resubmitted claims status check until a determination (payment or denial) has been made
Automation of supporting documentation required with the appeal submission for unpaid and underpaid claims.
Payments and adjustments are automated for posting to the customer system
Automation of first-time claims denial and reason tracking
Helps to improve cash flow and reduce claims management cost
Automation of claims error checking and payer time limit
Automation of code and policy updates
Identification of accounts that are eligible for re-submission with the discharge status code correction, resulting in the appropriate higher reimbursement
Automation of accounts receivable analysis to identify root cause trends and non-payable charges.
Automation of end-to-end revenue cycle services and management of Pharmacy claims – pricing; billing; follow up; appeals; post status, payments, adjustments; and custom reporting.