Transforming Payment Integrity Audits with Artificial Intelligence
Artificial Intelligence (AI) is no longer a futuristic concept — it’s here, and it’s transforming healthcare in real time. From clinical decision support to patient engagement, AI is helping organizations deliver better outcomes at lower costs. One of the most promising, yet often overlooked, applications is in payment integrity (PI), where accuracy, efficiency, and provider trust are critical.
The Challenges Facing Payers
Health plans today are navigating a perfect storm:
Escalating medical costs and inflation.
Persistent workforce shortages and administrative burdens.
Increased regulatory scrutiny and complex network contract negotiations.
Growing competition and pressure to deliver more value to members.
Payment integrity teams are at the center of this challenge. Their role — to detect, correct, and prevent payment inaccuracies — is more important than ever. But traditional processes are heavily manual and resource-intensive, making it difficult to scale.
How AI Elevates Payment Integrity
AI transforms claims auditing by removing inefficiencies, strengthening accuracy, and reducing abrasion.
Audit Workflows: Automate review processes in DRG, Inpatient Bill Review, quality and compliance, and high-dollar claims.
Coordination of Benefits: Verify primacy logic and analyze claims quickly, eliminating repetitive tasks.
Performance Management: Track vendor and audit outcomes in real time to detect trends and optimize strategy.
Audit Selection: Machine learning identifies high-ROI cases, allowing auditors to focus on where they add the most value.
Throughput Gains: AI handles the heavy lifting, enabling teams to audit more claims faster without sacrificing quality.
The Benefits in Practice
Shift to Pre-Pay Models: Prevent overpayments before they occur — stopping costs at the source rather than chasing them downstream.
Optimized Vendor Stacks: Compare vendor performance with real-time precision, ensuring every dollar spent on partnerships drives value.
Improved Hit Rates: Fewer false positives mean fewer unnecessary provider touchpoints, preserving relationships.
Machine-Grade Accuracy: AI never tires. Every claim is reviewed with consistency and rigor, reducing human error.
Looking Ahead: Agentic AI in Payment Integrity
The next evolution of AI — agentic AI — can dynamically adapt to new data, guide workflows autonomously, and continuously learn from results. This creates a future where PI is not reactive but proactive and predictive, protecting margins while reducing friction with providers.
The Lyric Difference
At Lyric, we believe AI should not just help teams “do more with less.” It should help them do more of the right work with less effort. By empowering PI teams with advanced AI, health plans can reduce costs, increase operational quality, and strengthen relationships with both providers and members.
Ready to see AI in action for payment integrity?
About Lyric
Lyric, formerly ClaimsXten, is a leading AI healthcare technology company, committed to simplifying the business of care. Over 30 years of experience, dedicated, expert teams, and top technologies help deliver up to $14 billion of annual savings to our many loyal and valued customers—including 9 of the top 10 payers across the country. Lyric’s solutions leverage the power of machine learning, AI, and predictive analytics to empower health plan payers with pathways to increased accuracy and efficiency, while maximizing value and savings. Lyric is investing in AI driven technology to ease implementation and speed to value for customer savings, while offering enhanced and newly available solutions through internal product development and strategic partnerships, including recently announced partnerships with Concert Genetics, Autonomize AI, and now, Codoxo. Discover more at Lyric.ai.
