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AI and machine learning revolutionize the health insurance industry

Health insurance policy changes at the federal level have captured the headlines in recent years, but in the long run some of the most profound changes to the industry have happened behind the scenes. The application of artificial intelligence and machine learning have impacted some of the industry’s most important practices.

These technologies begin working before a customer ever signs up for a policy, thanks to AI-driven advances in personalized marketing. Big data-driven marketing campaigns identify and effectively target potential high-value customers through the right channels, at the right time and with the right message to reduce cost of acquisition and increase profitability. This leads to improved customer lifetime value, especially when it forms the seed of a growing AI and machine learning-empowered relationship with the customer.

Once the customer is active, AI and machine learning help keep them happy through powerful customer service capabilities. Automated tools provide customers with the information they’re looking for (and reduce customer service headcount), while AI-processed claims move faster and decrease frustrating wait time for customers and providers alike. And while appropriate reaction is important, AI systems can often go a step further and identify and resolve issues before the customer even realizes they exist.

That problem identification is one small facet of the massive revolution in fraud, waste and abuse processes powered by AI and machine learning systems. This process is merging with traditional coordination of benefits functions and overall duplication and error control into a “payment integrity” function. This combines both proactive and reactive capabilities to make a major difference in insurers’ bottom lines. Rather than the traditional “pay and chase” model that pays claims then works to recover wrongful payments from customers, providers or third parties, AI and machine learning systems combine insightful analysis with human expertise to not only identify specific incidents, but also work toward eliminating root causes and closing dangerous vulnerabilities.

One reason payment integrity systems can make this revolutionary impact for health insurers is their ability to invert the traditional claim-centered model of adjustment and instead place the customer at the center of the analysis. Most fraud, waste, abuse and errors are driven by something inherent in the customer, rather than with the individual claim. Starting with the customer creates new opportunities to proactively identify claims for investigation, and the efficiency of machine learning systems means that the bar for minimum claim size for profitable adjustment can be set low enough to open up an entire new universe of potentially-recoverable payments. Best of all, just like human employees who gain expertise in their roles, machine learning systems get better over time at identifying recoverable claims and eliminating false positives.

Government health insurance policy matters, and it grabs the headlines. But while policy might change tomorrow, the revolutionary advances powered by artificial intelligence and machine learning are here to stay.

Interested in what they might mean for your business? Contact us to find out more.


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