Annual cost of medical claim overbilling addressed
10X
Reduction in data exposure risk
$10M+
Savings projected customer savings in first year
The Challenge
Combatting Inaccurate Billing Practices in the Healthcare System
Medical billing errors, such as upcoding, unbundling, and incorrect coding, cost the U.S. healthcare system over $200 billion each year. These errors create a financial burden on patients, insurance companies, and healthcare providers alike. The insurance provider needed a solution to detect and address these errors accurately while ensuring compliance and protecting patient data privacy.
highlights
Upcoding: Billing for a higher-level procedure than was performed.
Unbundling: Separating comprehensive procedures into individual claims.
Incorrect Coding: Human errors or intentional misrepresentation causing overbilling.
Data Privacy Concerns: Risks associated with handling sensitive PHI data.
Complex Billing Procedures: Challenges in accurately translating medical services to standardized codes.
The Solution
Privacy-Preserving RAG for Medical Claims
Using advanced data protection and AI to streamline medical billing.
Step 1
Ground Truth Dataset Creation
Curate detailed clinical notes
Map notes to accurate billing codes
Regularly update dataset integrity
Step 2
Sensitive Data Masking
Detect PHI in claims data
Mask data without losing usability
Keep data consistent across sessions
Step 3
AI-Powered Similarity Search
Convert notes to vectors for analysis
Run real-time similarity checks
Identify patterns in billing errors
The Results
Realizing Millions in Savings While Safeguarding Patient Data
Successfully implemented secure, AI-powered billing verification system to combat $200 billion in medical overbilling. By ensuring PHI compliance through advanced data masking and using AI-powered billing validation, Protecto enables accurate, efficient claims processing while protecting patient data privacy.
Key Achievements
$10 Million Savings: Projected annual savings from improved claim accuracy.
50% Reduction in Billing Errors: Through automated validation and secure data handling.
Zero Data Privacy Violations: With full compliance and data protection for PHI masking.
20% Faster Claims Processing: Streamlined workflows reduce processing times for insurers.
Improved Data Integrity: Consistent, accurate insights preserved even after data masking.
Ready to Transform Your Medical Claims Processing?
Discover how Protecto can help you combat medical overbilling while maintaining HIPAA compliance and data security.
Download "Reducing $200B Medical Overbilling Challenge with Protecto"
Discover how Protecto’s secure AI-powered solution helped a leading insurer reduce medical overbilling by $10 million annually while ensuring full PHI data protection compliance. Learn more!