5 Ways to Transform Your Healthcare Compliance Program Using AI

When you hear “artificial intelligence and compliance,” what first comes to mind? Initially, you might think of how critical it is to maintain compliance when using AI in healthcare. But have you considered the flip side—how you can use AI to optimize your healthcare compliance program?

With some foresight and strategic planning, you can leverage AI to streamline your compliance programs, reduce human error, and keep up with rapidly changing healthcare regulations. You may even be able to generate ways to use AI to help overcome the very same compliance challenges AI presents.

Maintaining Compliance While Using AI in Healthcare

What are your biggest hurdles regarding compliance and AI? For many healthcare execs – from compliance officers to HR leaders – challenges can include:

• Data privacy concerns – AI is an excellent tool for analyzing healthcare data that has been de-identified, but there is a very real risk of re-identification. A team of researchers concluded that 99.98% of Americans could be re-identified in any dataset using 15 demographic characteristics. This means that the detailed medical and demographic data that organizations collect to meet modern research methods could be precisely what prevents their ability to anonymize data appropriately and securely.

• Lack of explainability – AI can operate using “black-box” algorithms, which have hidden decision-making processes, making it difficult-to-impossible for clinicians to understand. In recently published research, Sara Gerke, associate professor of law at the University of Illinois Urbana-Champaign, and her team provide the example of Corti AI, a software that leverages machine learning to help emergency dispatchers make decisions. Its algorithms are considered “black box” because the Danish company’s “inventor does not know how the software reaches its decisions to alert emergency dispatchers that someone has a cardiac arrest.” How, then, can a compliance leader demonstrate how automated systems comply with regulations when audited? The lack of knowledge in these instances can be a challenge for medical professionals.

• Evolving regulations – Recent Supreme Court decisions, including the overturn of the Chevron doctrine (which left the interpretation of ambiguous federal statutes up to individual regulatory agencies), have further complicated the roll-out and adoption of AI and machine learning tools. Keeping up with rapidly changing laws can be demanding and time-consuming for busy healthcare leaders.

• AI bias and ethical issues – AI biases can arise from various processes, including data access, acquisition, collection, development, preparation, processing, and validation, recent data AI training data may not appropriately represent all racial and ethnic minority groups and underserved populations. This AI bias can create ethical dilemmas for leaders, exacerbating existing health inequities and disproportionally benefitting well-resourced individuals, according to commentary provided by Irene Dankwa-Mullan, MD, MPH, on the U.S. Centers for Disease Control and Prevention website.

• Training and adoption – For AI tools to be effective, clinical and non-clinical staff members need adequate training. Leaders may face barriers, including varying levels of AI literacy, lack of infrastructure to integrate AI into curriculum, limited time to teach new skills, and limited access to technology experts and AI trainers, as described in this review.

Top 5 ways AI can help leaders streamline healthcare compliance

So, how can you use AI to improve compliance, including addressing some of the same compliance issues AI creates? Consider these ideas as you develop your strategy. A caveat: Take care to run any new AI uses past your medical, legal, regulatory, IT, and compliance experts before implementation, and be sure to keep up with changing regulations.

1. Use AI tools to automate and analyze medical records and claims data to ensure compliance in coding and billing

AI can rapidly sort through massive amounts of data, such as tens of thousands of ICD, CPT, and HCPCS codes. It can capture data at various points along the patient journey, including registration, labs, treatment, and prescription. Plus, AI can detect coding errors humans often miss. AI tools for billing and coding can help leaders maintain compliance with Medicare, Medicaid, private insurance payers, HIPAA, the False Claims Act, the Joint Commission, and the Accreditation Association for Ambulatory Health Care among others.

2. Implement AI tools that use continuous monitoring or predictive analytics to reduce risk.

AI can be utilized to identify patterns – like medication errors, increased likelihood of readmissions, or fraudulent activities. For instance, at Reims University Hospital, scientists developed “a machine learning-based tool that prioritizes patients at risk of medication errors upon admission to the hospital to ensure that they undergo medication reconciliation by clinical pharmacists.” The AI tool showed a 113% improvement over their existing tool.

3. Employ AI to help prevent fraud.

Healthcare fraud costs an estimated $100 billion per year (U.S. Department of Justice). AI can help prevent healthcare fraud, including prescription fraud, false claims, phantom billing, upcoding, and unbundling of services.

AI systems can “detect abrupt increases in atypical services or unusually large claim volumes from a provider to identify charging for services not given,” says Certified Information Governance Expert Isaac Asamoah Amponsah. “Identical submissions for the same service or patient can also be used to highlight duplicate claims. In addition, clinical data and billing records can be analyzed by these algorithms to identify services—like over-testing for straightforward illnesses—that are not medically required.”

4. Get AI’s help with audit management

There are various AI-driven compliance automation tools on the market designed to assist compliance leaders with audit management and planning. AI can help you organize and plan for audits, gather and manage required documents and data, and keep records of all compliance-related actions. It can also generate detailed reports to facilitate review and keep you prepared for unexpected audits.

5. Use AI-powered workforce training and education tools

From personalized learning platforms and simulation-based training environments to AI-powered content-creation tools and chatbot-based learning systems, AI can help leaders ensure all team members understand compliance regulations. AI can be used to create personalized learning journeys and develop competencies that have a positive impact on provider compliance and patient care.

Get compliance education for your team

How can you help create a culture of compliance at your organization? HealthStream has a modern adaptive approach to compliance education called ComplyQ. Learn more about our Compliance Solution, ComplyQ.