Healthcare tends to lag behind other verticals when it comes to digital transformation, but the gap is particularly pronounced when comparing payers to organizations in other information-intensive industries such as banking and general insurance. The need to catch up has never been greater, as healthcare costs continue to rise faster than government reimbursement rates.
If payers are to create the efficiencies that will empower them to maintain (or even grow) their margins amidst an uncertain economy, adopting automation and AI can no longer be seen as optional. According to a recent analysis by McKinsey & Co., AI solutions could save $150 to $300 million in administrative expenses and reduce medical costs by $380 to $970 million for every $10 billion in payer revenue. AI adoption could also drive annual revenue increases between $260 million and $1.24 billion for that same health plan.
Health plans have been working to digitize their claims management and core administrative processes for years now, but many of these efforts have taken place within silos. What’s needed is large-scale, experience-led transformation, particularly in areas like provider lifecycle management (PLM), medical management and member outreach and support.
Let’s take a closer look into some of these operational areas, highlighting how AI and automation can help payers drive revolutionary new efficiencies.
Medical Management
Intended to ensure that only high-quality care is delivered—while controlling costs—medical management processes continually monitor and evaluate the services delivered to members for medical necessity, adherence to clinical practice guidelines and appropriateness. Key activities in medical management include prior authorization, medical necessity reviews, care and case management and clinical policy development and monitoring.
By leveraging a AI-driven platform to analyze clinical documentation and recommend for or against prior authorization in accordance with evidence-based guidelines, health plans can reduce manual reviews and cut processing time from days to hours. Payers that implement a next-generation utilization management platform can automate up to 85% of the tasks within prior authorization intake and triage workflows, accelerating turnaround time and improving accuracy.
The right solution can streamline processes, create new efficiencies, enable zero-touch approvals for eligible cases. A solution that includes an electronic data interchange gateway that supports HL7, FHIR and X12 transactions will enable bi-directional data exchange, making it possible for health plans to gather high-value information they can use to improve their relationships with providers.
In the past, most medical necessity and clinical policy reviews were done manually by medical directors. Taking advantage of GenAI to create clinical summaries of each relevant record can greatly accelerate clinical review processes, making it possible to get more accurate responses more quickly for claims and appeals.
AI can also be used to improve care management processes. Predictive models can analyze claims data, electronic health records (EHRs) and social determinants of health (SDOH) data to identify high-risk members. These members can then be targeted for proactive interventions (such as recommending preventative screenings or sending appointment reminders). A solution like Sutherland’s SmartHealthAnalytics platform can provide real-time analytic insights that payers can use to improve care coordination.
Provider Lifecycle Management
Provider lifecycle management (PLM) incorporates all of the processes and workflows that payers use to maintain mutually-beneficial relationships with providers and provide members accurate data to their provider network. Through effective onboarding, credentialing, provider data and directory management and performance monitoring, health plans can help their members access high-quality care while maintaining regulatory compliance and building trust.
AI-driven solutions allow payers to analyze and optimize their networks, identifying gaps in specialty coverage or geographic reach. GenAI can craft personalized recruitment emails and even contract proposals, making it faster and easier to engage with providers.
Member, Provider and Employer Group Outreach
Payer organizations need to develop and follow targeted outreach strategies to engage key stakeholders like providers and employer groups, as well as to build strong relationships with their members. New agentic AI solutions are enabling health plans to conduct omnichannel outreach campaigns, so that they can reach members where they are (e.g., email, text messaging, online portal, voice calling) and increase engagement without adding operational overhead. These automated solutions can reduce member outreach manual effort by 40% or more, reduce outreach attempts by 60% and lower operational costs by 30% or more. AI-enabled solutions also gather valuable analytic data on these interactions, enabling health plans to continuously improve their member support operations and better their relationships with providers. GenAI can automatically summarize conversations, draw attention to recurring issues that arise during support calls and help stakeholders define next steps for improving their programs.
How the Right Partner Can Help
Implementing emerging technologies like AI beyond proof of concept can be complex, but leveraging the expertise of an industry-leading partner will make it much easier. Sutherland is an experience-led digital transformation company with deep domain knowledge in healthcare and a strong customer focus. We’ve made major investments in AI and automation, and are committed to helping our healthcare customers drive change through their adoption of these technologies.
Want to know more about how we’re removing the boundaries of the possible for providers? Download our latest white paper here.