Alaffia Health uses AI to detect errors in hospital bills • TechCrunch

The rise in health care costs over several decades is not expected to reverse any time soon. In search of a solution, Adun Akanni and TJ Ademiluyi co-founded health wellness In 2020, a startup participating in TechCrunch Disrupt Battlefield 200. Healthtech is using machine learning to try to identify fraud, waste and abuse in healthcare claims.

“We leveraged key insights from our family’s medical billing company to found Alaffia,” Ademiluyi told TechCrunch in an interview. “We have determined that the majority of waste in the system is caused by natural human error, a lack of transparency in claims processing, and incompatible incentives between healthcare providers and payers. We founded Alaffia to address these issues using emerging machine learning and artificial intelligence, built on the highest expertise in deep healthcare. “.

Wellness primarily sells services to health insurance payers and companies that provide health coverage to their employees. By using artificial intelligence to extract and standardize data from hospital bills, including various medical billing procedure codes and service dates, the platform aims to reduce payer spending by finding errors and overcharges in bills sent by healthcare providers.

The causes of medical billing errors are myriad, but often arise from double billing, missing a payer submission deadline, and failure to obtain patient information. Unspecified diagnostic codes are another common problem, which leads to cases of overcoding and undercoding. Coding is when the programmer reports a service of a higher standard than patients have received or not performed before, while lower coding is when the billing codes do not capture the full scope of the work the physician is doing.

Medical expenditures are expected to grow at a rate of 5.1% from 2021 to 2030, to reach $6.8 trillion, according to for the Centers for Medicare and Medicaid Services — and a large portion of these expenses are derived from errors in health insurance claims. it’s a estimated That about 80% of claims in the US contain at least one medical billing error, and that up to $300 billion Lost To presenter fraud, waste and abuse every year.

health wellness

Image credits: health wellness

“This is a very challenging technical issue due to the lack of data standardization in the healthcare system, so we rigorously trained machine learning models using training data generated by our in-house annotation team,” Ademeloye said.

The Wellness Company reviews facility bills for errors such as “disassembly” – the use of multiple codes for individual parts of the procedure – while verifying the accuracy of more complex claims such as implants and surgeries. The company says it turns to registered nurses, certified programmers, and certified billers to indicate AI results, as well as the clinical review team that examines each claim and the corresponding medical record.

When asked about competitors, Ademeloy said he sees “legacy participants in the industry” manually processing and reviewing claims as the wellness company’s main competitors. But the wellness company isn’t the only startup trying to tackle the medical billing error problem with artificial intelligence. abnormality, which works with insurance companies and their providers, offers an AI-driven platform designed to detect irregularities in medical bills. There is, too NeemIts technology turns medical charts and electronic medical records from physician consultations into automatically auditable billing codes.

Wellness has managed to gain traction in space — and finance. Ademiluyi claims that the company’s services currently cover more than 300,000 health plan members in total. To date, the wellness company has raised $6.6 million in venture capital from backers including Anthemis, 1984 Ventures, Aperture Venture Capital, Tau Ventures, Twine Ventures, Plug and Play Ventures, Remarkable Ventures Fund, and ERA’s Remarkable Ventures Fund.

Ademiluyi says 2022 revenue is on track to more than double year-over-year. He added that the plan in the near term is to expand the wellness company’s commercial footprint and product offerings, starting with hospital bill review services directly to patients. The company currently employs just over 20 people and expects to hire five more by the end of the year.

“Fortunately, we operate in a recession-resistant industry. Regardless of epidemics, macro trends or interest rate expectations, people will still visit the doctor for care.” “When patients receive care, it leads to more spending on healthcare, which benefits our business as we review hospital bills for errors. As we navigate the slowdown in the market, large organizations – the health insurance organizations and the employers we support actually look for ways to to cut their expenditures, which we are directly supporting by reducing healthcare spending. As such, we believe that the pandemic and the current slowdown in the economy are net positive for business.”

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