As health plans look to implement, optimize, or modernize their core administrative platforms and integrated systems, Generative AI presents a compelling opportunity to drive efficiency and elevate customer satisfaction. But what exactly is Generative AI, and how can payers harness its capabilities to enhance their operations?
Once considered a cautious tech adopter, healthcare today is now at the forefront of a transformative tech boom. Both health systems and health plans are increasingly turning to advanced tools like automation, artificial intelligence, and machine learning to improve efficiencies, cut costs, and enhance the member experience.
Among these innovations, Generative AI is emerging as a powerful solution for payers, offering the ability to reimagine business processes and deliver operational improvements. By automating manual, labor-intensive tasks and processing vast data sets, Generative AI reduces errors, speeds up workflows, and generates insights that improve decision-making. Whether you’re focused on optimizing claims processes, predicting and managing risk in member populations, or enhancing the overall member experience, Generative AI can help streamline operations, deliver faster and more accurate results, and lower costs.
Here are three business areas where Generative AI can enhance efficiencies and deliver real value for your organization:
Enhance Claims Adjudication with GenAI for Faster Processing and Reduced Costs
When a claim is submitted, it either processes through the rules engine based on its configuration or is flagged and pended due to a system edit such as a high dollar amount or other qualifying condition. Claims may also be pended for reasons such as being out-of-network or validation requirements around coordination of benefits. These rules determine whether the claim is automatically processed or routed into a work queue for further review. Generative AI can play a pivotal role by assessing whether there is sufficient medical necessity to continue to hold a pended claim and can even trigger correspondence to validate other payer coverage.
Generative AI enhances the claims review process by pulling claims from work queues and applying an additional layer of analysis before manual intervention is necessary. This not only improves auto-adjudication rates and boosts throughput but also reduces the costs associated with manual intervention and claims that linger, potentially accumulating interest.
By leveraging Generative AI, your organization can streamline the claims process through automatic verification of clinical eligibility and benefits, identification of anomalies like coding errors or fraud, and review of new claims against historical data to determine if additional medical management is needed. This approach enhances efficiency and accuracy in authorization decisions, ultimately decreasing the number of claims requiring manual review and minimizing penalties from delayed processing.
Transform Customer Experience with GenAI for Faster Resolutions and Better Satisfaction
Generative AI can also transform the customer service experience for health plans by providing faster, more accurate responses to member inquiries. As a customer service agent working in a contact center, handling complex benefit questions can often be time-consuming. For example, when a member calls to ask about their remaining physical therapy (PT) visits, the traditional approach requires manually navigating the claims system to check their plan details. With Generative AI, this process becomes far more efficient.
AI can instantly analyze the member’s claims history and benefit plan, quickly providing information such as how many PT visits have been used and how many remain. This allows agents to deliver insights to the member faster, enhancing the overall experience. Instead of spending time manually searching through records, agents are automatically fed relevant data, enabling them to be proactive rather than reactive.
This improvement in efficiency leads to faster resolutions, better call throughput, and the potential to reduce call volume altogether. Members receive the information they need more quickly, leading to higher customer satisfaction (CSAT) scores and an overall positive experience with the health plan. In turn, this helps payers strengthen their member relationships and improve operational efficiency.
Revolutionize Care Management and Population Health with GenAI
You can also greatly optimize your approach to care management and population health by leveraging Generative AI to implement proactive, data-driven strategies targeting chronic diseases like diabetes, COPD, asthma, and more. The primary goal in care management is to support sicker populations and effectively manage complex, chronic conditions. By integrating Generative AI with care management platforms and population health tools, health plans can monitor and address these conditions more efficiently.
For example, in diabetes management, health plans often begin by establishing clear benchmarks for a target cohort, such as identifying members with both diabetes and obesity. Once these benchmarks are set, Generative AI can conduct disease surveillance by analyzing claims histories and population health data. This enables AI to identify patterns not only in members already diagnosed with diabetes but also in those at risk, allowing care managers to intervene proactively before issues escalate into more serious and costly conditions.
Additionally, by examining claims histories and identifying trends in members’ health, Generative AI can uncover factors that contribute to complex diagnoses like diabetes combined with obesity. Armed with this information, health plans can implement preventative measures, such as outreach and coaching for pre-diabetic members. This proactive strategy can enhance health outcomes and reduce overall care costs by preventing the progression of chronic conditions. Moreover, health plans can track the impact of Generative AI in preventing these diagnoses among at-risk populations, ultimately improving population health outcomes.
Getting Started: Using Generative AI to Create Actual Insights
These are just a few examples of the numerous business cases where Generative AI can significantly enhance your operations, elevate member satisfaction, and drive cost savings. The potential applications of Generative AI are vast, spanning from member outreach and onboarding to pricing and benefits design. As a health plan, your immediate challenge is determining where to begin your journey with Generative AI.
To tackle this challenge effectively, it’s essential to focus on use cases that can deliver immediate, measurable benefits. Every health plan operates with its own unique, customized systems, so the first step is to identify areas where Generative AI can address high-cost, high-volume challenges. For instance, if your organization processes tens of thousands of claims annually in specific categories like coordination of benefits for member coverage, these manual interventions may be costing significant time and money. Such repetitive, labor-intensive processes are prime candidates for AI-driven optimization.
Once you’ve identified the problem area, the next step is to partner with an expert team like Emids. We can help you explore how Generative AI can drive operational efficiency and improve your bottom line. From discovery to implementation and ongoing support, we’ll guide you through each phase to ensure the technology is seamlessly integrated and delivers lasting results.
Contact Emids today to learn how Generative AI can streamline your payer operations and boost member satisfaction.