How the “Human-in-the-Loop” approach to AI is Transforming Payment Accuracy

Artificial intelligence has taken the world by storm, promising to revolutionize industries from tech to healthcare. But as exciting as AI can be, it’s not a one-size-fits-all solution. When it comes to payment accuracy in healthcare, the magic happens when humans and AI work together. At TREND, we’ve built our approach around this synergy—because we believe the future isn’t humans vs. AI. It’s humans and AI, making each other better.

AI is like a microscope—it can magnify patterns and anomalies hidden in vast oceans of data. But it’s the scientist, the human, who interprets what it all means. That’s how we see payment accuracy. AI is brilliant at identifying patterns, automating repetitive tasks, and analyzing data at lightning speed. Humans, on the other hand, bring nuance, judgment, and the kind of high-level thinking that no algorithm can replicate.

• AI flags an overpayment due to a mismatched DRG code. While AI pinpoints the anomaly, it’s a seasoned analyst who recognizes that a recent policy update, overlooked by the system, justifies the billing. Together, they ensure accurate results and foster provider trust.
• AI identifies excessive billing on a high-cost drug. A human analyst steps in, reviews the claim, and spots a clinical trial exemption that justifies the cost. The result? Unnecessary appeals are avoided, and compliance with payer policies is ensured.
• AI detects an anomaly in a batch of claims, flagging them for potential overpayment. An analyst digs deeper and uncovers a unique contract provision specific to a regional provider group. Adjusting the review criteria, they refine the AI’s accuracy for future claims processing.

This isn’t just automation; it’s amplification. TREND’s intelligent agents handle the repetitive, rules-based tasks, freeing humans to focus on the tough stuff—the high-level analysis and decision-making that can’t be automated.

One of the most exciting applications of human-in-the-loop AI is its ability to smooth out payer-provider relationships. Let’s face it: this dynamic has been fraught with friction for decades. Disputes, clawbacks, and denials have created a system that feels more adversarial than collaborative.

TREND’s approach is different. By using AI to identify payer-side errors before they escalate, we’re not just fixing problems; we’re preventing them. Imagine catching recurring overpayment patterns before they require clawbacks. This proactive approach reduces provider abrasion and builds trust—because nothing says “partnership” like solving problems before they become pain points.

How do you know what tasks are best suited for AI and what should stay in human hands?

Here’s a simple guide:

• Handling exceptions that require complex decision-making.
• Applying ethical and compliance judgments.
• Refining strategies and innovating based on AI insights.

This framework ensures that AI and humans each play to their strengths, delivering results that are accurate, efficient, and fair.

At TREND, we don’t just use AI—we use it responsibly. Our human-in-the-loop philosophy is rooted in transparency, collaboration, and a commitment to better outcomes for everyone involved. Here’s how we’re different:

• • Unmatched Insights: Drawing from years of provider-focused strategies, we offer payers a window into the provider mindset, enabling smarter, more empathetic decision-making.
  • Proactive Policy Benchmarking: Our AI doesn’t just find errors; it helps clients compare their policies against industry standards, driving continuous improvement.
  • Trust Through Transparency: By combining AI-driven analysis with human judgment, we ensure that every decision is explainable and every outcome is defensible.

As AI continues to evolve, so will TREND. We envision a future where:

• TREND builds tools and frameworks to help clients transition to AI-centric models, complete with extensive training programs for AI literacy.
• Our workforce becomes AI-augmented, with analysts serving as “AI supervisors”—resolving complex cases and refining AI models.

The possibilities are endless, but one thing remains constant: the belief that the best results come from collaboration—between humans, AI, and the organizations we serve.

The healthcare industry is at a tipping point. By embracing human-in-the-loop AI, payers and providers can not only enhance their operational efficiency but also transform their relationships and, ultimately, patient outcomes. So here’s the question: Are you ready to join the movement? Together, we can build a smarter, fairer, and more collaborative future.

This article is part of TREND Health Partners’ thought leadership content series, reflecting our belief that focusing on people—not just processes—creates better outcomes for organizations and for healthcare as a whole. At TREND, we know that empowered individuals lead to collective success, which is as true in personal health as it is in the healthcare back office. Click here to read more from our team or subscribe to our content.