Agentic AI for Healthcare Claim Denial Analysis: A Policy-Grounded Framework for Privacy Preservation

원문 초록

In the healthcare sector, claim denials impose significant financial and administrative burdens, emphasizing the need for automated and trustworthy decision-support systems. This paper proposes a modular Agentic Artificial Intelligence (AI) framework for healthcare claim denial analysis, integrating specialized agents for denial risk prediction, risk factor identification, diagnosis-procedure-medication code relationship analysis, and counterfactual analysis. The framework integrates predictive analytics, graph-based learning, a Hybrid Contextual Retrieval-Augmented Generation (RAG) pipeline grounded in healthcare policy documents, and a dedicated HIPAA Compliance Agent to support privacy protection. Evaluated on a synthetic healthcare claims dataset, the framework achieved 98% traceability of reported numerical findings, validated 214 of 216 policy citations, and removed all 280 identified sensitive identifiers without modifying the underlying analysis. These findings pave the way for further research into Agentic AI as a framework for explainable, policy-aware, and privacy-preserving healthcare claim denial management.