What You Should Know:
– Oracle Health has unveiled a new strategy to strengthen the collaboration between healthcare providers and payers.
– The company plans to introduce a comprehensive suite of AI-powered apps and agents designed to automate prior authorizations, reduce claims denials, and improve care coordination. These solutions aim to significantly cut down on administrative costs, which are estimated at approximately $200B annually, and enhance value-based care initiatives.
Reducing Friction with AI Agents
The new suite of clinically integrated, AI-based applications is designed to target major points of friction between payers and providers, including prior authorization, eligibility verification, medical coding, and claims processing. By embedding AI agents that are “payer-rules aware,” providers can apply specific rules during patient workflows, leading to cleaner submissions and faster processing.
Oracle’s initial offerings will focus on simplifying several key processes:
- Prior Authorization: The Oracle Health Prior Authorization Agent can automatically identify the need for prior authorization, retrieve documentation, and submit digital requests to payers, eliminating the need for faxes and phone calls.
- Eligibility and Coverage Determination: The Oracle Health Eligibility Verification Agent is designed to help providers accurately determine patient eligibility and provide price transparency at the point of care, helping to prevent “surprise billing.”
- Medical Coding: The Oracle Health Coding Agent will work with a documentation agent to autonomously generate medical codes for all types of clinical settings. Payer-provided coding guidelines can be pre-applied to reduce errors.
- Claims Processing: A series of agents, including the Oracle Health Charge Agent, Oracle Health Contract Agent, and Oracle Health Claims Agent, will work together to ensure accurate claims submission, allowing payers to “left shift” their rules into the provider workflow.
Supporting Integrated Value-Based Care and Data Exchange
Beyond administrative tasks, Oracle’s new solutions will also support value-based care. Health systems using Oracle Health Data Intelligence can leverage payer-provided insights to close care gaps and improve patient outcomes. A new care and risk coding gaps capability will integrate insights from payers into provider workflows at the point of care, simplifying processes and helping to improve HEDIS and pay-for-performance outcomes.
To accelerate data exchange, the planned products will integrate with Oracle Health Clinical Data Exchange, a centralized network designed to replace manual record transmission with a secure and automated system. This is expected to allow payers to retrieve encounter data directly from the EHR and leverage event-driven updates, further streamlining collaboration and reducing administrative costs across the industry.
