Artificial Intelligence as a Tool to Mitigate Administrative Burden, Optimize Billing, Reduce Insurance‐ and Credentialing‐Related Expenses, and Improve Quality Assurance Within Health Care Systems

Despite spending $4.3 trillion annually on health care with $3.4 trillion ($10,193 per capita) attributed to care delivery, the United States still experiences the worst health outcomes among high-income countries. Administrative costs are the second largest contributor, with $353 billion ($1,055 per capita) spent annually. Addressing clinical and administrative fragmentation can reduce annual costs by up to $265 million and increase health care productivity, both of which contribute to care delivery that is necessary, effective, equitable, and fiscally responsible. In the advent of electronic health records, big data, and artificial intelligence (AI), there is an unprecedented opportunity to leverage these tools to drive meaningful improvements in high-value care delivery and reduce both clinical and nonclinical administrative costs. Physician engagement to develop comprehensive musculoskeletal data management systems is a critical precursor to the subsequent application of AI analytics. The incorporation of AI tools developed from these data systems both within organizations and seismically across the health care system can (1) promote transparency via payer/provider data-sharing platforms; (2) automate routine, evidence-based care to reduce ineffective, inefficient, and inconsistent medical decisions; (3) align incentives of key stakeholders by incorporating epidemiologic informatic insights and individual patient-centered value quantification to inform physician-patient decision making; (4) mitigate care delays from prior authorization and claims processing via centralized digital claims clearinghouses; (5) guide payment model evolution to accurately and transparently reflect costs of care for patients with different risk profiles; (6) harmonize quality control reporting for comparability; (7) simplify and standardize prior authorization processes to reduce administrative complexity; and (8) automate nonclinical repetitive work (credentialing, quality assurance, and so on). Adoption of these tools can eliminate $168 billion in annual administrative costs. Although no single solution will perfectly transform health care, the strategic and responsible use of AI technologies could lead to transcendent improvements in delivery of health care that is patient centered, equitable, efficient, and fiscally responsible.