We are a multi-hospital healthcare network that partnered with Viston to reduce claim denials, speed up prior authorizations, and improve patient support without compromising PHI security.

Business Challenge

Claim denial rate at 12.8%, long prior authorization cycles (72 hours median), and 27% of patient inquiries waiting over 10 minutes for resolution.

Contact center average handle time was 8.6 minutes with inconsistent documentation quality.

Our Approach and Solution

Viston conducted a HIPAA-first data audit, signed a Business Associate Agreement (BAA), and deployed an isolated Azure tenant with PHI redaction and FHIR-first integrations.

Medical Coding Copilot

Developed a Medical Coding Copilot with Retrieval-Augmented Generation (RAG) over payer rules, ICD-10/HCPCS codes, and historical approval data.

Prior Authorization Summarizer

Implemented a Prior-Authorization Summarizer that compiles clinical notes and payer guidelines into submission-ready authorization packets.

Patient Support Assistant

Deployed an AI-powered Patient Support Assistant for appointment scheduling, benefits eligibility, and patient preparation instructions, with seamless human-in-the-loop escalation.

AI Applications and Benefits Delivered

Clinical Summarization and Denial Prediction

Applied NLP and Retrieval-Augmented Generation (RAG) for clinical summarization, claim denial reason prediction, and intelligent patient intent classification.

Business Benefits

• Reduced claim denials
• Faster prior authorization approvals
• 24/7 patient support with safe human handoffs
• Improved documentation consistency

Cost of Implementation

USD 165,000, including cloud infrastructure, software licenses, security hardening, and six months of MLOps support.

Time to Implement

14 weeks for the pilot implementation, followed by 10 weeks to scale across three hospitals.

Tools and Technologies Used

• Azure OpenAI (GPT-4 class)
• Azure Cognitive Search
• FHIR Server
• Databricks
• LangChain
• n8n
• Microsoft Power BI
• Azure Key Vault
• Azure Private Link

Quantitative Outcomes

• 31% reduction in claim denial rate (from 12.8% to 8.8%)
• 46% reduction in median prior authorization cycle time (from 72 hours to 39 hours)
• 38% contact center deflection for routine patient inquiries
• 27% reduction in average handle time (from 8.6 minutes to 6.3 minutes)
• 3.2× return on investment (ROI) within 10 months

Key Performance Indicators (KPIs) Tracked

• Claim denial rate
• Prior authorization turnaround time
• Average Handle Time (AHT)
• First Contact Resolution (FCR)
• Customer Satisfaction Score (CSAT)
• PHI leakage incidents
• Model accuracy for medical intent classification

Pre- and Post-Implementation Metrics

• Claim Denial Rate: 12.8% → 8.8%
• Prior Authorization Time: 72 hours → 39 hours
• Average Handle Time (AHT): 8.6 minutes → 6.3 minutes
• Customer Satisfaction (CSAT): 4.1/5 → 4.5/5

Stakeholder Quotes

VP, Revenue Cycle

“Viston gave our teams superpowers while meeting our HIPAA bar. The coding copilot alone paid for itself in under a year.”

Regulatory and Compliance Considerations

• HIPAA compliance
• SOC 2 Type II compliance
• Business Associate Agreement (BAA) in place
• PHI redaction
• Audit logging
• Least-privilege access controls
• Model governance with prompt and response retention policies