LOS ANGELES, April 21, 2021 /PRNewswire/ -- Pearl, the leader in AI solutions for efficiency, accuracy, and consistency in dental care, today announced that the United States Patent Office has issued Pearl U.S. Patent No. 10,937,108 entitled "Computer Vision-Based Claims Processing." The patent covers the novel computer vision technology underpinning the company's Claims Review® and Pearl Protect® solutions for automating dental insurance claims adjudication. This is the second patent recently awarded to Pearl for machine learning innovations developed to eliminate waste and improve productivity within essential dental industry processes.
"We expect all dental insurance carriers to be powering their claims review with AI within the next five years––and when that happens, it will be thanks to a technology that Pearl introduced."
The dental insurance industry's core cost management apparatus – utilization management – is also its largest cost center. Despite prodigious investment in claim adjudication infrastructure and headcount, insurance carriers succeed in reviewing fewer than 10% of the billion-plus dental insurance claims – amounting to $85 billion in industry-wide payouts – submitted annually in the United States. To maximize the impact of claim adjudication resources, carriers focus almost exclusively on high value claims––those requiring radiographic evidence of treatment need. Still, the teams of accredited clinicians that carriers employ as claims examiners are capable of evaluating only a tiny sample of radiograph-supported claims. The claims they review are selected on the basis of cost alone, without any governing logic to identify claims with higher likelihood of denial or to increase claims routing efficiency. When claims are denied, the subjectivity of examiners' findings offers little transparency into the rationale for denial. And because dental examiners are as prone to human diagnostic inconsistency as practitioners are, a certain portion of claims are denied in error. Incomplete, labor-intensive, nontransparent, imperfect––until recently, dental insurers have been obliged to accept these deficiencies in the utilization management enterprise.
Last year, however, Pearl introduced two products Claims Review® and Pearl Protect® to solve carriers' claims adjudication woes. These products are built around a pioneering technological process: The application of computer vision machine learning algorithms to automatically validate insurance claims based on radiographic claims evidence. Pearl's latest patent grants the company an expansive and exclusive license to apply computer vision algorithms for this purpose.
"We've given carriers the ability to process claims in seconds and, because a carrier's unique decision making matrix is defined in the system, its decisioning is totally transparent," says Pearl's CEO Ophir Tanz. "The carrier plugs the software in and instantly goes from reviewing a tiny fraction of radiograph-supported claims to programmatically reviewing every claim. Their adjudicators go from wasting time on claims destined for approval to focusing only on questionable claims where their expertise is most useful."
The patented technology automates claims processing using a range of machine learning models to diagnostically assess radiographic claim evidence, then cross-references the diagnostic findings with the claimed treatment codes. If the AI diagnosis accords with a carrier-approved treatment, the claim is automatically accepted. If not, the claim is routed to a human claims examiner for manual review.
"From the carrier's perspective, this technology is extremely simple to integrate and put to work, but under the hood it is complex," explained Cambron Carter, Pearl's CTO. "Before a claim reaches our decisioning engine, the radiographs run a machine learning gauntlet where fingerprinting and image recognition models mitigate malicious behavior like radiograph doctoring, GANs intelligently correct image quality, segmentation models and detectors conduct anatomical orientation and diagnosis, then all findings are combined using clinically-informed heuristics to measure the severity of conditions like decay, bone loss caries, etc. This all happens in the blink of an eye, but when you understand everything that's going on in that blink, you can understand why, as a team, we're particularly proud to receive this patent."
Echoing those sentiments, Tanz added that the company's recent patent successes signal Pearl as the predominant innovator and trusted partner in the dental AI ecosystem.
"AI adoption is approaching an inflection point in the dental industry. We expect all dental insurance carriers to be powering their claims review with AI within the next five years––and when that happens, it will be thanks to a technology that Pearl introduced."