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Article . 2025
License: CC BY
Data sources: ZENODO
ZENODO
Article . 2025
License: CC BY
Data sources: Datacite
ZENODO
Article . 2025
License: CC BY
Data sources: Datacite
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Artificial Intelligence Driven Compliance Automation Improving Audit Readiness and Fraud Detection within Healthcare Revenue Cycle Management Systems

Authors: Getrude Frimpong; Amina Catherine Peter-Anyebe; Onuh Matthew Ijiga;

Artificial Intelligence Driven Compliance Automation Improving Audit Readiness and Fraud Detection within Healthcare Revenue Cycle Management Systems

Abstract

The integration of Artificial Intelligence (AI) into healthcare revenue cycle management (RCM) systems is revolutionizing compliance automation, audit readiness, and fraud detection across the healthcare enterprise. This review explores how AI-driven compliance automation frameworks leverage machine learning (ML), natural language processing (NLP), and robotic process automation (RPA) to ensure real-time regulatory adherence, minimize billing anomalies, and enhance audit transparency. By analyzing data across claim submissions, coding accuracy, denial management, and payment reconciliation,AI systems enable predictive risk scoring and anomaly detection to identify irregular claim patterns indicative of fraudulent activities or noncompliance. Furthermore, explainable AI (XAI) models are increasingly used to provide interpretability in compliance decision pathways, supporting auditors in tracing logic-based evidence trails during regulatory reviews. The study also examines the role of generative AI in automating documentation compliance, particularly in aligning electronic health records (EHRs) with Centers for Medicare & Medicaid Services (CMS) and Health Insurance Portability and AccountabilityAct (HIPAA) standards. A comparative assessment of legacy compliance models versus AI-augmented systems highlights significant reductions in falsepositive fraud alerts, audit preparation time, and operational overhead. This paper highlightss the convergence of AI analytics, data governance frameworks, and healthcare informatics in shaping a resilient, transparent, and fraud-resilient RCM ecosystem. Future research directions include the standardization of AI auditing protocols, ethical governance in algorithmic decision-making, and the integration of federated learning for privacy-preserving fraud analytics across multi-institutional datasets.

Keywords

Artificial Intelligence, Compliance Automation, Audit Readiness, Fraud Detection, Healthcare Revenue Cycle Management.

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
0
Average
Average
Average
Green