Reducing Fraud and Improving Payment Integrity in Healthcare Through the Use of AI

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    About the Report

    HL7’s new report, Reducing Fraud and Improving Payment Integrity in Healthcare Through the Use of AI, is a product of its Strategic Initiative on AI to Counter Fraud — one of three initiatives launched by HL7 as part of its ongoing work to accelerate the responsible use of artificial intelligence (AI) to improve health and healthcare. 

    The report summarizes the current landscape and opportunities for using AI to improve payment integrity and reduce fraud, waste and abuse. It synthesizes insights from a broad range of stakeholders, including payers, providers and technology experts. 

    As healthcare costs continue to rise, there is a need for increased focus on reducing fraud, waste and abuse in the healthcare system. AI promises to significantly improve healthcare payment and counter fraud. However, interoperability and electronic data capture from multiple systems, while protecting patient privacy, and careful integration of AI outputs into healthcare data and workflows, are required to fully realize AI’s benefits. This report offers recommendations for realizing these goals.

    Key Findings

    1. AI has significant potential to transform healthcare fraud detection and payment integrity, while also improving the transition to value-based care
    2. Successful implementation requires thoughtful standards development and frameworks that address explainability, transparency, data governance, and validation
    3. Pilot programs focused on provider-payer collaboration represent a promising path forward

    Participants further emphasized that standards development should lead to actionable outcomes rather than theoretical frameworks, with particular attention to facilitating faster valid claims processing while effectively identifying payment errors or fraudulent activities early in the process, prior to payment. 

    Immediate Recommendations

    Commence working groups to develop standards or frameworks for explainable AI, transparency, data segmentation, and validation.

    Initiate planning for pilot programs focused on provider-payer collaboration to improve payment integrity.

    Engage with federal and state agencies to ensure alignment with existing and emerging regulatory and payment approaches.

    Envisioned Outcomes

    Trusted AI tools are adopted to improve payment integrity and identify potential fraud while simultaneously streamlining valid claims processing.

    Providers and payers collaborate effectively around payment, supported by interoperable systems and standards, to reduce administrative burden and improve payment accuracy.

    AI models and related standards reflect and inform evolving regulatory requirements and payment models, including value-based care.

    About HL7 and Acknowledgements

    Health Level Seven® International (HL7®) is an ANSI-accredited, not-for-profit standards developing organization with the mission of empowering global health interoperability. With affiliates in over 30 countries, HL7’s global membership envisions a world in which everyone can securely access and use the right data when and where they need it.

    In 2024, HL7 launched an effort focused on artificial intelligence led by HL7 CEO Charles Jaffe, MD, PhD. In its first year, HL7 launched three strategic initiatives, one of which is the Strategic Initiative on the Use of AI to Counter Fraud and Improve Payment Integrity, led by co-chairs Janet Marchibroda and J. Marc Overhage, MD, PhD, in collaboration with David Bray, PhD, MSPH, of the Stimson Center. This report is a product of this strategic initiative.