Waystar deploys agentic AI to handle claims, denials, and documentation.
Waystar has introduced agents that analyze payer responses and automatically resubmit denied healthcare claims, which it refers to as the first autonomous resubmission capability in the industry. Germany limits the number of hospital invoices subject to audit each quarter and imposes a flat fee when one is reduced.
An American company has developed software that independently negotiates with insurers. Waystar's agents interpret a payer's denial, apply that payer's guidelines, determine the next steps, and resubmit the claim without assistance.
The scale of this operation is a key selling point. Waystar handles over 7.5 billion healthcare payment transactions annually and claims to reach approximately 60% of US patients, providing its agents with the necessary historical data to function effectively.
The economics behind the issue are unique. Payers ultimately approve about 70% of claims they initially reject, but this approval comes after providers incur costs to resubmit them, and the time delay in this process is what is being automated.
All performance metrics are attributed to the vendor. A 75% reduction in analysis time comes from early adopters and may differ by organization, while the anticipated 25% decrease in documentation review is expected but not quantified, and the claim of "industry's first" is the company promoting its own release, a limited benefit in essence.
The most significant disclosure pertains to the associated risks. Waystar highlights the variability in AI claims-matching accuracy among payers and the potential for payers to alter the appeals and recoupment procedures that the agents were designed to navigate.
Europe is also automating health administration, but not this aspect. This year, NHS England provided Copilot to 505,000 staff members within a system that generates hardly any denied claims to pursue.
Where Europe engages in this dispute, it is restricted by legislation. Germany restricts the number of hospital invoices a sickness fund can submit for medical auditing each quarter to 5%, 10%, or 15%, based on how many of that hospital's bills passed the previous review.
Additionally, there are financial penalties for failure. As of December 2024, a hospital incurs a flat €400 fee when an audit leads to the reduction of one of its invoices, serving as a limit on the disputation rather than encouraging ongoing arguments.
The regulations surrounding AI do not encompass these issues. The AI Act classifies risk assessment and pricing in health insurance as high-risk but does not address the processes involved after a bill is issued.
Europe’s health regulators are aware of this discrepancy. In July, WHO Europe cautioned that nearly two-thirds of countries in the region utilize AI diagnostics, yet only 8% have a comprehensive health AI strategy.
Thus, the distinction is not about superior software. The United States is automating disputes on a large scale, while Europe has established regulations to streamline the argument process.
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Waystar deploys agentic AI to handle claims, denials, and documentation.
Waystar's new agents independently resubmit denied insurance claims. In Germany, there are restrictions on the number of hospital bills that can be contested, and each bill is assigned a price.