Generative AI could revolutionize the way businesses operate. For health plans, it may enhance member experiences, optimize network management, and streamline administrative processes. Health plans can improve profitability with generative AI in several ways, including those outlined below.
What is Generative AI?
Generative AI is artificial intelligence that can generate new content, such as text, images, audio, and code. It learns from existing data and patterns to create new, original outputs. The emergence of ChatGPT signaled the beginning of the generative AI boom.
Personalized Member Experiences
Because generative AI ingests large amounts of data to decipher patterns and create new outputs, it can deliver better member experiences. Two examples include:
Tailored Recommendations
Leverage generative AI to create personalized health recommendations based on individual member data, including medical history, lifestyle, and preferences.
These tailored recommendations can improve profitability by encouraging better health outcomes while reducing costs.
Proactive Outreach
Identify members at risk of non-adherence or chronic conditions and proactively reach out with personalized support and interventions.
This outreach can help prevent expensive healthcare interventions, improving profitability.
Focusing on personalized member experiences helps health plans better serve members, improving member retention and satisfaction scores.
Optimized Network Management
Health plans can leverage generative AI to optimize provider networks, recommend quality, cost-effective providers, and improve provider negotiations. Here’s how:
Provider Selection
Health plans can leverage generative AI to analyze provider performance data to identify high-quality, cost-effective providers for network inclusion. Quality metrics may include readmission rates, mortality rates, and adherence to clinical guidelines. They can also analyze patient feedback and satisfaction surveys to identify providers with great patient experiences.
Negotiation Support
Generative AI can also help health plans visualize data-driven insights to inform contract negotiations, ensuring favorable terms for the health plan. Plans can leverage historical data to identify trends and successful negotiation strategies. Or, they can leverage data to analyze market rates and the competitive landscape, improving negotiations. Health plans may also leverage generative AI to analyze contracts for terms, clauses, and potential areas for negotiation.
These activities can help improve negotiating leverage, drive down costs, and ultimately improve profitability.
Enhanced Claims Processing
Managing claims is a core administrative function within health plans. Streamlining the claims process serves as a focal point for improving profitability. Here are two ways generative AI can enhance claims processing:
Fraud Detection
Estimates say claims fraud costs anywhere from $15 to $83 per participant monthly. Though health insurers have automated up to 85% of claims reviews, health plans may be able to leverage AI to identify patterns of fraudulent claims, reducing losses and improving accuracy.
Adjudication Automation
Though most health insurers have automated a significant portion of the claims adjudication process because AI can ingest large amounts of data to discover patterns, AI may help automate the remaining claims processes. Those reduced administrative costs and improved efficiency can enhance profitability.
Predictive Analytics
AI can integrate data from various sources, including claims data, medical records, demographics, social determinants of health, and wearable device data. AI enables a more holistic view of each member’s health profile. Combining large amounts of data with AI algorithms that can identify complex patterns and relationships within the data may result in surprising findings that lead to new strategic direction.
Among the use cases that can impact profitability:
Risk Stratification
Risk stratification helps identify members at a higher risk of experiencing adverse health events or incurring high healthcare costs. Health plans can then implement interventions to improve member health outcomes and reduce overall costs.
Trend Forecasting
Don’t you wish you could see into the future? When COVID hit, many health plans wished to forecast trends to determine strategies to improve profitability. With generative AI, health plans can leverage data to predict future healthcare trends and adjust strategies accordingly, such as anticipating changes in drug costs or disease prevalence.
For example, we’ve talked to many health plans struggling to implement the billing requirements of the Medicare Prescription Payment Plan (M3P), including the Likely to Benefit Notice requirements. Not only can AI help identify those most likely to benefit, but it can predict member enrollment. The expectation is that enrollment will increase further when CMS requires point-of-sale enrollment in the plan, which AI may be able to predict so plans can understand the operational impact.
Certifi’s health insurance billing and payment solutions help payers improve member satisfaction while reducing administrative costs.
