Comparative performance: Rule-based vs. AI-driven healthcare claim processing systems

Gawande, Pramod Dattarao (2025) Comparative performance: Rule-based vs. AI-driven healthcare claim processing systems. World Journal of Advanced Engineering Technology and Sciences, 15 (3). pp. 2153-2160. ISSN 2582-8266

This article presents a comprehensive comparative analysis of rule-based and artificial intelligence (AI)-driven healthcare claim repricing systems across multiple performance dimensions. Through an extensive evaluation spanning numerous healthcare organizations over a multi-year period, the article shows fundamental differences in accuracy, efficiency, regulatory compliance, and stakeholder impact between these competing approaches. The article employs rigorous methodological frameworks, including automated audit mechanisms, HIPAA-compliant data pipelines, and state-specific policy engines to generate empirical evidence of AI systems' superior performance in complex healthcare administrative environments. Findings reveal that AI-driven implementations demonstrate significant advantages in pricing accuracy, provider dispute reduction, regulatory adaptability, processing efficiency, and long-term cost-effectiveness despite higher initial investment requirements. The article concludes with strategic recommendations for healthcare organizations considering technological modernization and identifies promising directions for future research and broader applications within healthcare administration.