Becker’s Healthcare Podcast From Detection to Prevention: AI’s Role in Payment Integrity
Jan 27, 2026
Steve Sutherland, Senior VP of Information Systems at CERIS with nearly 30 years in healthcare IT, explains how AI is changing payment integrity. He covers the move from post-payment audits to prepayment solutions. He talks about ML and LLMs extracting data from complex records. He stresses governance, fairness, human oversight, and preparing IT for AI-driven workflows.
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Payment Integrity Covers The Whole Claims Lifecycle
- Payment integrity now spans the full claims lifecycle from submission to final payment, not just post-payment audits.
- AI is central to this shift and organizations are only beginning to tap its potential while facing governance and data challenges.
Shift From Pay-And To Prepayment Audits
- AI has driven a major shift from post-payment ('pay-and') models toward prepayment solutions that audit during the payment cycle.
- Rapid adoption surprised Steve, but governance and oversight efforts must catch up to development speed.
AI Unlocks Unstructured Medical Records
- The clearest impact of AI is turning large, unstructured documents into structured, machine-readable data for faster processing.
- Machine learning and LLMs detect ambiguous narrative patterns that rule-based systems miss, especially in medical records.