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June 6, 2023

Part 1: Basics of Artificial Intelligence (AI) and Healthcare Compliance


Artificial intelligence (AI) technology has created new opportunities to progress on critical issues such as health, education, and the environment. In some cases, AI may do things more efficiently or methodically than humans.

AI is the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages, according to the Oxford dictionary. 

In its simplest form, artificial intelligence is a field, which combines computer science and robust datasets, to enable problem-solving. It also encompasses sub-fields of machine learning and deep learning.

The ideal characteristic of artificial intelligence is its ability to rationalize and take actions that have the best chance of achieving a specific goal. A subset of artificial intelligence is machine learning (ML), which refers to the concept that computer programs can automatically learn from and adapt to new data without being assisted by humans. Deep learning techniques enable this automatic learning through the absorption of huge amounts of unstructured data such as text, images, or video.

According to Investopedia’s article “Understanding Machine Learning: Uses, Example,” machine learning is the concept that a computer program can learn and adapt to new data without human intervention and is a field of artificial intelligence that keeps a computer’s built-in algorithms current regardless of changes in the worldwide economy.

ChatGPT has become one of the most talked about advancements in technology. GPT-3, the underlying technology powering ChatGPT, can generate content that is almost indistinguishable from text written by humans. Many believe it is poised to revolutionize the way people communicate with each other and machines.  There are many potential applications of ChatGPT in healthcare, and the extent to which ChatGPT might improve healthcare may cause a profound shift in our healthcare systems.

Let’s define these terms:

OpenAI:       A company focused on developing Artificial General Intelligence (AGI)

ChatGPT:     A product created by OpenAI that functions as an AI-powered chatbot platform for businesses and individuals

GPT-3:           A technology leveraging an advanced natural language processing (NLP) model that uses deep learning to generate human-like text

AI and Government Health IT Infrastructure

The Office of the National Coordinator for Health Information Technology (ONC) and the Agency for Healthcare Research and Quality (AHRQ), with support from the Robert Wood Johnson Foundation, turned to JASON, an independent group of scientists and academics that has been advising the Federal government on matters of science and technology for over 50 years, to consider how AI might shape the future of public health, community health, and healthcare delivery.  The experts outline three forces that explain why the time may be ripe for AI in healthcare:

  • Frustration with the existing – or legacy – medical systems among patients and health professionals
  • Ubiquity of networked smart devices in society
  • Comfort with at-home services like those provided through Amazon and other technology companies

Moving forward, ONC and AHRQ will work closely with other Department of Health and Human Services’ agencies, including the National Institutes for Health (NIH) and the Food and Drug Administration (FDA) to define and identify possible opportunities for the use of AI in their efforts to improve biomedical research, medical care, and outcomes, including work related to the advent of precision medicine.

Can ChatGPT Replace a Physician? 

OpenAI’s ChatGPT 2023 & the National Institutes of Health

AI is developing at lightning speed.  The government’s National Institutes of Health (NIH) published an article in February 2023 entitled “Opportunities and risks of ChatGPT in medicine, science, and academic publishing: a modern Promethean dilemma.” The article asks the same question – can ChatGPT replace physicians?

According to NIH “AI has a tremendous potential to revolutionize health care and make it more efficient by improving diagnostics, detecting medical errors, and reducing the burden of paperwork; however, chances are it will never replace physicians. Algorithms perform relatively well on knowledge-based tests despite the lack of domain-specific training; ChatGPT achieved ~ 66% and ~ 72% on Basic Life Support and Advanced Cardiovascular Life Support tests, respectively, and performed at or near the passing threshold on the United States Medical Licensing Exam. However, they are notoriously bad at context and nuance – two things critical for safe and effective patient care, which requires the implementation of medical knowledge, concepts, and principles in real-world settings.”

AI Use in Healthcare Research & Quality

As posted in the American Institute of Healthcare Compliance (AIHC) June monthly newsletter, the Agency for Healthcare Research & Quality (AHRQ) grantee is testing AI for use to improve breast cancer screening accuracy and efficiency.  AHRQ funding will test whether artificial intelligence (AI) algorithms can improve the overall accuracy of the breast cancer screening process, make workflow more efficient and help improve the patient experience. Based on the algorithm’s review, the exam may be flagged as suspicious for immediate review by a radiologist to determine whether further diagnostic examination is needed, all while the patient is still at the clinic.

We can all be hopeful that use of AI will improve disease diagnosis and monitoring, clinical workflow augmentation, and hospital optimization.

Can AI Streamline Medical Coding & Billing Functions?

Medical coding and billing is a complex process that involves translating healthcare services, diagnoses, and procedures into standardized codes. These codes are then used for billing purposes, as well as for maintaining patient records and facilitating communication between healthcare providers and insurance companies. However, this process is prone to errors, which can lead to claim denials, delayed reimbursements, and increased administrative costs.

According to the American Medical Association (AMA), the most common mix-ups creating coding problems are: unbundling codes, upcoding, failing to check National Correct Coding Initiative (NCCI) edits, and failure to append appropriate modifiers.

Due to the complex nature of accurate coding, charge capture, billing and reimbursement, AI technology holds the potential to transform medical billing.  This is certainly an area where advanced technology is needed to reduce overhead, improve compliance and reduce billing errors.

Current Electronic Health Record (EHR) systems are expensive, require modifications to templates as codes are added, deleted and revised frequently.  AI can also be used for medical billing denial management to reduce the risk of denied claims and increase revenue. Some ways in which AI can be used for medical billing denial management: predictive analytics; automated appeals; real-time monitoring; root cause analysis; and performance metrics.

Computer-assisted coding and billing has been around for some years now, but introducing artificial intelligence with machine learning algorithms can elevate the entire system.  However, it remains to be seen whether expert coders, auditors and clinical documentation improvement professionals could be replaced.  AI technology would empower these professionals.  Beware of new companies offering such services.  Due-diligence is necessary to ensure their system has been tested, is compliant to government and payer standards and is affordable moving forward as AI evolves and our system or contract service with the company advances.

AI and Compliance Challenges

Compliance oversight and increased skill your organization will require to ensure HIPAA security of information is a major concern to consider.  ChatGPT by OpenAI is used to automate medical coding and billing processes.  But can it be hacked????

While a user can do amazing things with ChatGPT, there are concerns over safety, privacy, and its use by cybercriminals and online scammers. Bodies as diverse as Samsung and the Italian government have initiated bans on the use of ChatGPT, while experts have called for a pause in AI development.

ChatGPT Data Leak – On March 24, 2023, OpenAI, the creator of ChatGPT, confirmed that a bug in the AI’s source code resulted in a breach of sensitive data. The vulnerability was in the Redis memory database, which OpenAI uses to store user information. Actors were able to access the open-source library and view users’ chat history.

Furthermore, approximately 1.2% of ChatGPT Plus subscribers who were active on March 20th may have had payment information compromised due to the bug. The incident exposed names, email addresses, payment addresses, credit card types, and the last four digits of credit card numbers.  AIHC recommends reading OpenAI’s blog posted about the data breach: https://openai.com/blog/march-20-chatgpt-outage


Medical software dealing with patient data must be secure and HIPAA compliant. So, it goes without saying that AI-driven medical billing and coding applications that process critical financial and health data must meet these standards. Also, general coding, documentation and billing oversight for compliance to payer guidelines should be maintained by workforce experts.

Compromised personal data can have serious consequences, including identity theft, financial fraud, and job losses in addition to OCR HIPAA fines and costs associated with breach notifications. The best thing you can do is have reliable cybersecurity protection, and ensure you will find out ASAP in the event of being affected.  Then, reliable assurances that appropriate measures have been taken to prevent future occurrences.

Remember, software vendors are defined as Business Associates under HIPAA law, requiring your organization to operate with the vendor according to a Business Associate Agreement or “BAA”.  A business associate can be a healthcare app developer, a cloud service provider, a practice management or billing system, medical billing company or others storing and/or processing your patient’s data.

AIHC recommends training healthcare executives, managers and key workforce members in HIPAA privacy and security – training online available at: https://aihc-assn.org/courses/hipaa-compliance-officer/

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