Make claims management software smart!

Artificial intelligence (AI) is one of today's megatrends of technology. Siri, Alexa, automated image recognition systems; autonomous cars are examples of AI technologies that shape public perception.

The potential inherent in new technologies has been legitimately appreciated by the private sector. Self-learning software and cognitive systems can already be found in the value chain or about to be deployed: forecasting and pricing tools for purchasing and inventory management, chatbots for customer service, last mile delivery drones, etc. AI applications can help organizations optimize services and reduce costs, speed processes and make better decisions.

Similar development is underway in healthcare. Medical centers are increasingly using early detection systems supported by algorithms or automatic pattern recognition in patient data.

Less known are the opportunities that the use of smart technology brings to health insurers. Initial use cases have been found for IA-supported systems that improve care - for example, in the development of personalized offerings for patients with chronic conditions or to identify clinical pathways that do not meet the guidelines. Cognitive systems can help case managers to effectively analyze cases, evaluate them more accurately, and make informed decisions.

Intelligent algorithms, which learn from historical cases and evolve continuously, make traditional claims processing a thing of the past. The AI-supported system can systematically identify and correct errors while avoiding unnecessary or ineffective interventions.

Benefits for Health Insurers - Greater Efficiency, Meaningful Decisions

Integrating AI into the hospital claims management process offers multiple benefits to both insurers and patients, given the potential for savings. In short, moving away from rigid rule-based claims management to smart algorithms leads to greater efficiency and sound decisions - reducing the burden on all stakeholders and enabling savings.

Automated prioritization eliminates the need for administrative staff to verify each claim that is unusual, but can instead focus on those cases with the greatest potential for reduction and the best prospects for successful intervention. A comparative analysis of a prioritization procedure based on historical test data shows to what extent a cognitive system can predict this potential. The results show that the success rate of the algorithm is close to the ideal value - that is, the system correctly filters all refund requests, the amount of which can be reduced.

Not only does the cognitive system simplifies and speeds up the overall claims management process, but it also improves its quality: the additional costs of redundant audit and rejection processes are eliminated, while available resources can be focused on “proper” cases that really are relevant for audits. As a result, the system frees the capacity of administrative staff and auditors so they can correctly identify the reduction potential and properly prepare intervention cases, thus increasing their chances of success.

In the short time it has been in the insurance business, AI has increased efficiency and reduced labor costs in the processing of insurance claims. Ultimately, any action taken by an insurer must have one end goal: to attract new customers and retain existing ones by offering first-class service through all contact points. The treatment of claims infused by AI allows insurers to achieve this goal.

start investing in a suitable IT architecture now

The health insurers have not so far ventured into the new field of AI. The reasons for this slow adoption vary: uncertainty about practical use cases, gaps in technological expertise within organizations, or lack of transparency about available data. However, any health insurer can benefit from the use of artificial intelligence - provided the necessary conditions are met. It is therefore worthwhile to start investing in a suitable IT architecture now.

AI technologies will play a bigger role in the future management of healthcare. Health insurers should therefore seize the opportunity to position themselves at the wave top - and thus enable their organizations to be in a good position to meet the growing challenges in healthcare domain.

Martin
CTIO
At Spritecs Martin is responsible for defining key organizational strategy and setting the frame of new technologies implementation, while coordinating them to company’s stakeholders.

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