How PRIMESOFTWARE engineered an AI-driven, HIPAA-compliant claim processing engine that reduced billing denial rates by 38% and scaled annual processing to $400M+.
Our client, a multi-state hospital network with over 45 outpatient clinics, was struggling with legacy billing systems that relied heavily on manual data entry and outdated ICD-10 validation rules.
As a result, claim denial rates exceeded 18%, causing severe cash flow delays, compliance audit risks, and operational strain on billing staff.
PRIMESOFTWARE deployed a dedicated team of HealthTech engineers to build a custom microservices RCM platform integrated directly with the client’s Epic and Cerner Electronic Health Record (EHR) systems via HL7/FHIR APIs.
Bi-directional data synchronization extracting clinical notes, procedure codes, and insurance eligibility automatically.
Machine learning models trained on millions of historical claims to flag missing documentation before submission.
AES-256 encryption at rest and in transit with comprehensive immutable access logging for HIPAA compliance.
Within 90 days of rollout, the client achieved a 99.4% first-pass claim acceptance rate. The automated workflow freed up 25+ administrative staff to focus on patient care and complex audit disputes, unlocking over $14M in previously delayed revenue.
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