The growth of private healthcare systems and of the insurance market, together with the exponential increase in data — clinical, personal and financial — within ever more complex regulatory environments for data protection and for the electronic exchange of digital health information, is forcing rapid digital transformation across the healthcare sector, and with it a steadily growing demand for technology that optimises and automates processes.

The refusal of payment and the return of invoices on reimbursement requests — claim denials — by a payer, whether an insurer or another paying entity, to the healthcare provider (hospitals, clinics, physicians and others) is today one of the largest sources of revenue loss for providers, directly affecting operational continuity, business sustainability and the quality of care delivered.

In a regulatory environment that is increasingly hard to keep pace with, these denials and invoice returns are common practice, and can arise for any number of reasons: missing documentation, lack of coverage, unauthorised procedures, coding or administrative errors, among others.

It is against this backdrop that the "CDMS – Claim Denials Management Solution" project takes shape, setting out to develop an innovative integrated solution to manage and optimise providers' healthcare cost reimbursement processes, drawing on advanced hyperautomation and generative AI techniques to raise process efficiency while reducing risk and, with it, cost.