Why Payers are Turning to AI for Provider Contract Management

In the healthcare payer industry, contracts play a vital role in provider management: defining how providers are reimbursed, determining fee schedules, and outlining network participation terms. These contracts, however, are often filled with complex language and are spread across disparate systems, making it difficult for payers to accurately analyze them. This can lead to a myriad of issues like missed fee schedules, reimbursement escalations, and unclear terms that cause costly errors and inefficiencies. For payers, effectively managing contracts is crucial to ensure proper reimbursement and compliance.   

In this blog, we’ll explore how knowledge-enhanced large language models (LLMs) can revolutionize contract management workflows for payers, improving efficiency and delivering measurable business impact. 

What are Knowledge-Enhanced LLMs?

First, let’s understand knowledge-enhanced LLMs. These models, known to technical audiences as retrieval-augmented generation (or RAGs for short), are an AI framework that combines the strengths of traditional methods for data retrieval (i.e., querying databases) with the capabilities of generative LLMs (e.g., OpenAI). By combining these methodologies, AI is enabled to write more accurate, up-to-date, and relevant text for specific users.

The Contemporary Issue of Payer Contracts: Navigating Complexities of Provider Data 

In the healthcare payer industry, provider data—including contract language, pricing terms, and demographic details—is often siloed and spread across multiple systems and databases. This fragmentation not only complicates data access, but also has severe consequences for payers: 

• Inaccuracies and Inefficiencies: Disparate data systems and continuous amendments make it difficult to accurately capture and track contract terms, reimbursement details, and fee schedules, leading to errors that can result in overpayments, underpayments, or compliance violations. These inaccuracies can also affect network adequacy and provider directory accuracy, putting payers at regulatory risk. 

• Increased Costs: Without a unified platform to manage provider contracts, payers face higher operational costs due to the manual work required to reconcile contract terms across systems. This lack of efficiency can slow down claims processing, delay payments, and strain payer-provider relationships. 

• Bottlenecks in Business Functions: Essential teams such as claims processing, payment integrity, and cost of care management often experience delays because they rely on specialized contract teams for aggregating and synthesizing data. This creates bottlenecks that affect overall business performance, delaying financial reporting, compliance checks, and contract renegotiations. 

The consequences of failing to streamline provider data management extend beyond inefficiency—they also put financial stability, regulatory compliance, and payer-provider relationships at risk. By addressing these complexities, payers can not only reduce costs but also improve the accuracy and speed of critical business functions. 

Unlocking the Power of Knowledge-Enhanced LLMs for Streamlined Payer Contract Management 

The Intelligent Query Tool seamlessly integrates provider data from systems like Contract Lifecycle Management (CLM) and contract amendment platforms, streamlining contract management and improving workflows. It enables tracking every step of a contract's lifecycle, including updates like reimbursement rates and fee schedules, ensuring teams always have the latest information. Additionally, it supports contract audits by maintaining a detailed history of changes, enhancing accuracy and compliance. The tool automates contract management, reducing delays, improving decision-making, and ensuring compliance for payer organizations. 

Key Benefits for Payers 
Here’s how this integration transforms workflows for a payer: 

• Operational Efficiency: Centralizes data from multiple sources, enabling quick access and faster decision-making. 

• Cost Reduction: Automates manual tasks like fee schedule lookups and compliance checks, reducing labor costs. 

• Risk Mitigation: Provides real-time insights for proactive decision-making, identifying trends, and optimizing provider relationships and contract performance. 

 These benefits not only improve operational capacity, but also contribute to stronger financial performance and more effective provider network management for payer organizations. 

Ready to transform the way your team manages contracts and pricing? Discover how HiLabs’ Intelligent Query Tool can streamline operations, enhance accuracy, and drive cost savings for your organization. Contact us today to schedule a personalized demonstration and see our AI-driven capabilities in action! 

If you are interested in learning more about our solutions contact us today.