A health plan is reviewing a claim for a 35-year-old female with a prosthetic heart valve who presented to the Emergency Department complaining of rectal bleeding and a six-day heavy menstrual period. The patient was especially concerned because she takes Coumadin to help thin her blood and wanted to ensure she wasn’t bleeding too much. She was subsequently admitted to the hospital for three days with a diagnosis of Lower GI Bleed with a CC of Acute Posthemorrhagic Anemia.
The patient has a 232-page medical record, and the provider has submitted a claim for 378, G. I. Hemorrhage w/CC. A payer claims analyst has been assigned to review before payment. The health plan needed a way to accurately verify the DRG code and ensure the claim aligns with industry guidelines and insurance policies within a complex and extensive medical record.
CAVO® was able to simplify this process and complete it in a fraction of the time. CAVO’s intuitive AI-powered search functionality enabled the analysts to find relevant information within the medical record to verify the accuracy of the DRG code. In this case, analysts did not did not find adequate documentation of acute severe anemia. Therefore the claim was downgraded.
Previous, labor-intensive review methods involved manually indexing the medical record, creating a worksheet template, and reading each individual progress note and consult for determination. In this case, the estimated time spent was 130 minutes.
CAVO technology was able to perform the same workflow, using its built-in AI capabilities, in approximately 20 minutes.
That equates to a time savings of over two hours or a 288% increase in productivity.
Using CAVO’s advanced search logic and automated data extraction, CAVO expedited the review of a complex patient case. This efficient approach demonstrated cost savings and a reduction in administrative burden.
CAVO empowers highly skilled clinical and coding resources with AI-driven functionality that shifts the focus from “low value” tasks and requirements such as document access, search, analysis, and determination support within medical records and other unstructured data to “high value” tasks and requirements such as validation of predictive determination.
The technology enables clinical and coding resources to easily access and structure medical records, itemized bills, and additional clinical data efficiently, consistently, cost-effectively, and profitably and delivers the information in multiple intuitive interfaces to support dozens of use cases.