Transforming Medical Bill Review Through AI, Data Science, and Physician Oversight
WellRithms is redefining payment integrity through a fully AI-driven platform built for precision, scale, and defensibility.
Our proprietary Bill Review AI Decisioning engine (BRAID™) combines large language models (LLMs), OCR (Optical Character Recognition), and machine learning to identify billing inaccuracies and ensure fair, evidence-based medical reimbursements.
This case study illustrates how WellRithms’ technology safeguards both patients and payors through autonomous claim analysis supported by human clinical validation.
The Case: A $761,464.26 Hospital Bill for a 20-Day Stay
A police officer was hospitalized for 20 days following a severe open calcaneus fracture (heel bone injury) requiring multiple surgeries and skin grafts.
The resulting bill totaled $761,464.26, including charges that appeared legitimate at first glance — but weren’t.
Hospital bills of this scale often contain errors, duplicate line items, and inflated charges hidden within itemized statements. Without a detailed audit, these overcharges are commonly paid in full, creating unnecessary financial loss for payors and public institutions.
The Review: AI-Powered Line-Item Analysis with BRAID™
WellRithms deployed BRAID™, our proprietary AI decisioning engine, to conduct a full itemized bill review.
BRAID™ uses:
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LLM-powered OCR to digitize complex hospital documents, converting handwritten and unstructured data into clean, structured inputs.
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Predictive models and proprietary cost databases to evaluate each charge for accuracy and medical necessity.
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Agentic AI processes that autonomously flag inconsistencies, duplications, and violations of reimbursement policy.
Once the AI system completed its automated assessment, the review moved into human-in-the-loop validation — where physician experts confirmed every recommended adjustment using clinical and contractual evidence.
The Findings: 75% of Charges Invalid or Inflated
BRAID™ identified $573,682 in mischarges, leading to 75% verified savings:
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30 boxes of gauze, each costing less than one dollar, were billed three times, totaling over $60,000.
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$3,645 in implants were billed without documentation confirming use.
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An irrigation device appeared twice, billed at $8,317 per instance, despite being non-reimbursable.
After validation, the recommended payment was adjusted to $187,781.52, accurately reflecting medically necessary and contractually compliant charges.
The Result: Verified, Defensible Savings
When the hospital disputed the findings, WellRithms’ AI-driven dispute resolution system produced a complete reasoning trace — transparent documentation that linked every adjustment to clinical evidence and cost benchmarks.
Upon review, the facility withdrew its complaint, and payment was finalized at the WellRithms-verified amount.
This case secured over half a million dollars in savings for the department and taxpayers — and demonstrated the strength of WellRithms’ defensible, AI-powered payment integrity process.
The Platform Behind the Savings
WellRithms’ technology operates within an AWS-native AI/ML infrastructure, integrating:
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Amazon SageMaker for model training and continuous learning.
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Bedrock and HealthLake for secure, HIPAA-compliant data orchestration.
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Closed-loop feedback systems that continuously retrain models on verified outcomes.
The result is a scalable, explainable, and defensible AI ecosystem capable of performing billions of data evaluations — while maintaining human oversight and legal defensibility.
About WellRithms
WellRithms is the leader in AI-driven payment integrity, combining large language models (LLMs), OCR document intelligence, and agentic AI automation to eliminate overbilling and ensure defensible healthcare payments. Our proprietary Bill Review AI Decisioning engine, BRAID™, unites deterministic rules, predictive analytics, and medical reasoning into a single intelligent system that learns continuously from verified claim outcomes. Built within a HIPAA-compliant, AWS-native architecture using SageMaker, Bedrock, and HealthLake, WellRithms bridges the worlds of technology and medicine to deliver precision, transparency, and fairness in every review.
Through physician oversight and explainable AI, we ensure every determination is validated, auditable, and trusted — proving that when AI and medical expertise converge, accuracy isn’t theoretical. It’s measurable.
