Elevance Health executives detailed how the company is using AI and tighter claims review to manage costs during the company’s Oct. 21 earnings call.
“We are strengthening Medicaid cost management really by acting directly on the utilization and the payment patterns that are driving elevated trends,” CFO Mark Kaye said on the call.
Here are seven things for revenue cycle leaders to know:
1. AI is helping Elevance flag claims earlier. “AI-enabled analytics have helped us identify potentially inappropriate billing and utilization patterns earlier,” Mr. Kaye said. “The idea here is allowing our teams to investigate and respond more quickly.”
2. Elevance is expanding claims review and coding policies, including behavioral health payment guidelines, Mr. Kaye said. At the same time, the company is “streamlining authorization processes to support appropriate treatment with less administrative friction,” he said.
3. Applied behavior analysis therapy for autism is a focus. Felicia Norwood, Elevance’s chief health benefits officer, called it “one of the areas where we have seen very high utilization.” She said Elevance is using AI “to understand abnormalities in terms of claims” and will deploy its payment integrity capabilities to review claims “across the spectrum to avoid any type of misuse in the Medicaid space,” while preserving families’ access to care. Her comments follow an Aug. 4 CMS toolkit aimed at helping state Medicaid and CHIP agencies strengthen oversight of ABA services for children with autism.
4. Provider networks are also under review. “We are also thinking through our provider networks in markets to ensure better alignment of provider performance with affordability, while importantly preserving member access,” Mr. Kaye said. He said pharmacy management, reimbursement and site-of-care actions complement the work. Elevance views 2026 as the trough for its Medicaid margins and expects improvement in 2027, he said.
5. Elevance is using its Blues network access and BlueCard claims data to spot emerging claims patterns, Mr. Kaye said, and is applying those insights to the independent dispute resolution process. He said the company aims “to strengthen both the claims review and dispute validity around IDR.” IDR pressure has been “much more pronounced” in Elevance’s administrative-services-only business than in its fully insured business, he said. President and CEO Gail Boudreaux said the company is pushing for regulatory and legislative changes to the process. “We’re seeing significant process disputes, including claim eligibility awards, many cases way in excess of what is reasonable,” she said.
6. Elevance’s Elevate medical cost management platform has identified more than $300 million in anticipated savings this year, Ms. Boudreaux said. The platform “is helping our teams identify emerging cost drivers earlier and translate those insights into targeted action,” she said.
7. Alongside its payment integrity work, Elevance plans to require hospitals to identify on claims where care was physically delivered and to adjust payment for off-campus services accordingly. The company said Sept. 29 that the policies will apply across its commercial, Medicare Advantage and Medicaid plans. Elevance will check billing data against hospital addresses, pay certain off-campus hospital services at off-campus rates and block hospital-rate billing for lab tests performed at other locations. Elevance said it is the first commercial payer to go public with requiring physical location data on claims and tying reimbursement to it.
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