A Predictive AI Model for Proactive Denial Management in Healthcare Revenue Cycle: A Retrospective Cohort Study
10/21/2025 • BMJ Health & Care Informatics • License: CC BY
Jones, P.
Abstract
This study developed and validated a machine learning model to predict insurance claim denials. Using a dataset of over 5 million claims, the model identified claims with a high likelihood of being denied with 92% accuracy (AUC 0.94). This enabled the revenue cycle team to flag and correct potential errors before submission, leading to a 28% reduction in the overall denial rate and a significant decrease in costly rework and appeals.
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Clinical implications
An AI tool was successfully trained to predict which medical insurance claims would be denied before they were submitted. This allowed staff to fix errors proactively, resulting in a 28% drop in claim denials and saving the hospital significant time and money on appeals.
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