Healthcare Operations Transformed with AI Medical Coding

Implementation Team

About the Client

A large multi-specialty healthcare system in the United States, the client operates across 15 locations with over 500 physicians. Handling more than 2 million patient encounters annually, the organization plays a critical role in delivering coordinated care across primary, specialty, and urgent care services. However, their revenue cycle operations were under strain due to outdated manual coding processes and workforce limitations.

What The Client Faced

The client’s medical coding operations were heavily manual, leading to a cascade of operational and financial challenges:

High Error Rates: Manual coding introduced inconsistencies, resulting in frequent claim denials and revenue leakage.
Delayed Claims: Coding turnaround times averaged 48 hours, slowing down reimbursements.
Burnout & Bottlenecks: Workforce shortages and coder fatigue created operational delays and increased the risk of compliance issues.
Limited Scalability: The team struggled to keep up with growing patient volumes without adding headcount.

Proposed Solution

To address these challenges, the client partnered with CaliberFocus to implement an AI-powered medical coding platform built on Natural Language Processing (NLP) and machine learning. The solution was designed to automate and optimize the end-to-end coding workflow.

Key components of the solution included:

Real-Time Code Assignment: Automated generation of ICD-10, CPT, and HCPCS codes directly from clinical documentation.
Denial Prediction & Prevention: AI-driven claim scrubbing to flag potential issues before submission.
Human-AI Collaboration: Complex cases were routed for human review, ensuring accuracy without compromising speed.
Seamless Integration: The platform was integrated with the client’s EHR and billing systems for uninterrupted data flow.

Business Impact

The AI-driven transformation delivered measurable improvements across the board:

Coding Turnaround Time: Reduced by 85%, from 48 hours to just 6 hours on average.
Coding Accuracy: Improved from 78% to 96%, significantly lowering claim denials.
Faster Reimbursements: The reimbursement cycle was shortened by 9 days, accelerating cash flow.
Operational Efficiency: Staff productivity tripled, enabling the team to manage 3x more encounters without additional hires.

Metric	Improvement
Coding Turnaround Time	85% reduction (from 48 hours to 6 hours)
Coding Accuracy	Increased from 78% to 96%
Reimbursement Cycle	Shortened by 9 days
Staff Productivity	3x more encounters managed without new hires