Jan 28, 2026
Episode 2
16 mins
AI in Payment Integrity
This conversation digs into where payment integrity breaks at scale and why the industry is still saving thousands when it could be saving millions. We talk about implants as healthcare's most opaque profit center, how AI is fundamentally reshaping the auditor role from data gatherer to validation specialist, and why the real opportunities aren't in the low-hanging fruit everyone's already catching. Peter brings a rare outside perspective—starting in restaurants and IT before accidentally ending up in healthcare 23 years ago—and it shows in how AMS approaches problems differently than the rest of the industry.
We are stepping over dollars to pick up nickels. And there is a much, much better way to address this issue.
00:52 Introduction and background
• Peter's journey from busboy to Oracle consulting to healthcare by accident
• Why coming from outside healthcare felt like traveling back in time 20 years
• Cross-industry experience giving unbelievable perspective on how no other industry functions like healthcare
03:30 Payment integrity beyond the low-hanging fruit
• Why the industry saves thousands when it could be saving millions
• DRG audits with AI predicting 92% recovery confidence and approximate dollar amounts
• Moving beyond basic code edits to network contracts and reimbursement methodology at scale
05:47 Implants: healthcare's opaque profit center
• Nobody can answer how many parts are in a knee replacement or what they actually cost
• Price transparency data only tells you "how tall the cliff is you're about to jump off"
• Drug-coated stents billed at $40,000 that cost hospitals $2,800
08:26 AI changing the auditor role
• Shifting auditors from data gatherers to validation specialists
• AI bringing all payment integrity checks to itemized bills simultaneously
• Solving friction, labor intensity, and cost structure where it currently costs $2 to recover $1
10:36 Humans in the loop and industry adoption
• Healthcare adopting AI 2x faster than other industries for the first time
• The auditor shortage is a massive constraint that AI will alleviate, not eliminate
• We're stepping over dollars to pick up nickels
13:05 Lightning round
• Most egregious claims: $36-42 million premature baby bills
• Coding errors versus revenue optimization: why does this provider upcode every single time?
• Running a company with a sibling: "No one's ever going to have your back like a sibling"
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