Here’s a hard pill for hospitals to swallow: $262 billion in healthcare claims are denied annually in the U.S., with nearly two-thirds of those denials being avoidable. (Becker’s Hospital Review)
What if you could catch issues before they trigger a denial?
That’s where “Denials using AI” comes in.
This isn’t just about adding more dashboards. It’s about automating intelligence into the pre-bill stage, eliminating errors before they cost you.
In this blog, we’ll unpack what AI-driven denial prevention looks like, why hospitals are betting big on it, and how AI tools are reshaping the RCM playbook.
What is Denials using AI?
“Denials using AI” refers to leveraging artificial intelligence to predict, flag, and prevent claim denials before submission.
Unlike traditional denial management, which reacts after a claim is rejected, this approach shifts left.
It anticipates denial triggers and fixes them during pre-bill audits, documentation review, and coding validation.
Think of it as hiring an invisible audit assistant who never sleeps and knows payer policies better than your compliance team.
How denials using AI works
At a high level, here’s what AI does in denial prevention:
- Scans clinical notes, coding, and documentation in real time
- Cross-references payer-specific rules and NCCI edits
- Flags high-risk claims before they hit the clearinghouse
- Auto-suggests corrections or tasks for coding/CDI teams
What is denial using AI in healthcare?
In healthcare, denials are more than just admin annoyances—they directly impact operating margins.
Hospitals using AI for denials are solving:
- DRG validation errors (wrong code, missed CC/MCCs)
- Medical necessity mismatches
- Missing documentation
- Bundled vs. separate billing conflicts (NCCI)
AI models trained on historical claim outcomes and payer-specific edits can detect patterns humans might miss.
And when deployed at scale, it changes the game.
“For every 1% decrease in denial rate, a 300-bed hospital can recover $3-5 million annually.” HFMA
Role of AI in denials using AI
Here’s where AI shines in denial prevention:
Real-Time Coding Validation
- Checks DRG, CC/MCC, and ICD accuracy
- Flags mismatches with clinical documentation
Medical Necessity Prediction
- Analyzes EMR data for gaps
- Verifies that diagnosis supports tests and procedures
Audit-Readiness
- Creates an auto-log of flagged issues + resolution trail
- Helps compliance teams prep for RAC audits
Automated Task Routing
- Assigns flagged claims to coding/CDI/audit teams
- Tracks resolution to ensure no claim is missed
Payer-Specific Rule Matching
AI adapts to frequent CMS and private payer policy changes
How Bulwark helps with denials using AI
Let’s talk about ARC+, Bulwark’s AI platform for denial prevention. ARC+ is built to:
- Automate pre-bill audits
- Flag risky claims before submission
- Improve DRG accuracy and CC/MCC capture
- Ensure NCCI compliance
It doesn’t just tell you what’s wrong. It routes tasks, tracks fixes, and helps ensure cleaner claims all upstream.
Key ARC+ Modules:
- Pre-Bill Quality Check Engine: Detects coding/documentation issues
- Denial Prediction Model: Forecasts likelihood of claim rejection
- Task Routing System: Sends flagged cases to the right team
- Compliance Guardrails: Keeps you audit-ready year-round
FAQs:
How accurate is AI at predicting denials?
AI models can reach up to 95%+ accuracy in flagging high-risk claims, especially when trained on large payer-specific datasets.
Will AI replace coding or audit teams?
No. AI supports teams by automating the grunt work, not replacing human expertise.
What data does AI need to prevent denials?
Structured EMR data, historical claims, payer rule sets, and documentation patterns.
What types of denials can AI prevent?
DRG mismatches, medical necessity issues, NCCI bundling errors, and missing documentation are the most common.
Is AI helpful only for inpatient claims?
No. ARC+ supports both inpatient and outpatient claims.
Conclusion:
Denials aren’t just frustrating. They’re expensive.
But with ARC+, hospitals can finally move from reactive denial management to proactive denial prevention.
You’re not just protecting revenue. You’re freeing up time, reducing burnout, and building a clean, audit-proof pipeline.
If you’re tired of clawing back revenue after it’s lost, maybe it’s time to stop losing it in the first place.
Book a demo with Bulwark to see how ARC+ powers AI-driven denial prevention that actually works.
