Abstract
Healthcare providers lose substantial revenue to systematic payer underpayments and claim denials, yet identifying the recurring, correctable patterns behind them remains largely manual and does not scale to hospital claim volumes. We present Pattern Intelligence, a deployed system that discovers such patterns without supervision by clustering claims on their adjudication behaviour rather than their identity. Each claim is embedded in a 130-dimensional vector combining per-line expected-versus-actual payment ratios, claim adjustment reason (CARC) codes, denial and payment signals, and service composition. Payer and contract identity are deliberately excluded from the distance metric - we show they dominate the geometry and collapse clusters into trivial per-payer groups - and are reintroduced only as a post-hoc segmentation (by contract and visit type) that keeps every surfaced pattern coherent and actionable. We cluster with HDBSCAN, recover structure from the noise set via second-pass sub-clustering, and gate low-confidence memberships. A large language model translates each centroid into an analyst-ready description of dominant procedures, adjustment reasons, and failure mode. We report a recurring finding: roughly one-third to one-half of high-dollar denials, depending on tenant and segmentation, form an irreducible long tail that no density-clustering configuration or representation we tried groups - a domain property, we argue, rather than a modeling deficiency. We evaluate validity through cluster-coherence analysis and quantify impact with a recoverable-opportunity ($) metric on two production tenants (approx. 10K and 157K claims) within a six-tenant deployment. Rather than a new algorithm, the contribution is a problem formulation, a representation-design insight, and empirical findings from production.
Abstract (translated)
URL
https://arxiv.org/abs/2610.27684
