AI-Powered FHIR Billing & Eligibility Automation for Clinics

Details

This solution aims to modernize and automate the Revenue Cycle Management (RCM) for healthcare organizations, particularly dental and outpatient clinics, utilizing Azure cloud and AI technologies. The platform is built on Azure Health Data Services, which ingests and manages standard FHIR resources such as Patient, Coverage, Claim, and Task. A key feature is the automated calling capability to payers via Azure Communication Services. This enables real-time voice interactions for critical processes: eligibility checks (serving as a fallback when clearinghouse data is incomplete), claim status follow-ups, and pre-authorization criteria verification. Furthermore, AI services (OpenAI or Azure OpenAI) are triggered through FHIR Task resources, ensuring event-driven and auditable execution. These services automate tasks like form filling, generating denial explanations, recommending codes, and creating patient communication drafts. The system promises to automate up to 70% of billing workflows, accelerate insurance response cycles, and reduce claim denials through accurate pre-submission checks, all while maintaining interoperability and compliance using industry-standard FHIR.