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How insurers are leveraging artificial intelligence for future success

By Vijay Madyastha
Jun 3, 2020
5 MIN. READ
The healthcare industry is adopting artificial intelligence to improve efficiencies across the board, from interpreting patient test results to streamlining administrative tasks. The COVID-19 crisis is only speeding this up.

In the midst of the COVID-19 pandemic, healthcare insurers find themselves on the front lines—charged with helping their members stay healthy and providing as much assistance, guidance, and care as possible to everyone involved. Major sectors have been impacted, consumer behavior has shifted, and routines upended. Like most industries, healthcare is facing its unique set of challenges. In the midst of the COVID-19 pandemic, healthcare insurers find themselves on the front lines—charged with helping their members stay healthy and providing as much assistance, guidance, and care as possible to everyone involved. This will involve increasing resources where they are needed most, such as patient call centers and various other member-facing services that may be facing high volumes. As insurers look for ways to assist their members in this uncertain time, one area that is helping operationalize these efficiencies is the use of artificial intelligence, or AI.

The benefits of artificial intelligence in healthcare

The healthcare industry is using artificial intelligence to ingest, understand, and perform administrative and clinical healthcare functions. But there’s more that AI can do: the industry is starting to use it to understand patient test results, perform complex financial analyses, and even help doctors recommend treatment options. 

When insurers look to drive down costs, artificial intelligence can be a viable solution to impact the bottom line. Insurers can use artificial intelligence to leverage higher performing FTEs (full-time equivalent) for tasks and workstreams requiring more leadership and strategy, and identify areas that may deliver more significant value add for near- and long-term objectives and sustainability. They can deploy artificial intelligence to target and optimize areas such as claims adjudication, member enrollment, billing, and accounts receivable—along with certain legacy member-facing aspects such as customer service—to significantly streamline and enhance member-facing experiences.

To illustrate this, here’s an example. Take The American Heart Association, which puts the cost of cardiovascular disease in the United States as of 2017 at $555B and projects that by 2035, that cost will rise to  approximately $1.1 Trillion. HEARTio, a Pittsburgh-based startup currently undergoing the 501(K) clearance process, uses artificial intelligence to better identify cardiac abnormalities. Using data amalgamation combined with predictive analytics and deep learning methods, the company can better categorize a population’s risk of a cardiac event than a human can, thus working to mitigate human bias in healthcare. HEARTio estimates that further integrating AI into emergency departments can reduce costs by billions of dollars in both direct (i.e., cardiac triage) and indirect (i.e., work lost and insurance claims) costs.

Where and how is AI gaining traction?

Artificial intelligence is being put to use across the insurer operations spectrum. For example, a large insurer currently uses AI in the medical record review process: instead of having a nurse or physician review and align patient records with the insurer’s authorized policies and procedures, the insurer is using AI to determine whether the service rendered is ultimately reimbursable.

We are helping a number of healthcare clients identify and deploy artificial intelligence in their operations and member-facing experiences. With our support, an insurer vendor is using AI to assist insurers in determining which patients require intense care—which in turn warrants an increase in allocated resources and costs. Known as risk modeling, this is a vital component of insurer operations: if the premium is priced too low, it will result in more out-of-pocket expenses for insurers, but if it is priced too high, they risk losing membership.

We are also currently working with healthcare clients to provide data-driven solutions leveraging the power of artificial intelligence to deliver precision medicine that is personalized based upon unique individual profiles, targeted for better member outcomes. These personalized solutions use data and algorithms to provide targeted health insights and improve understanding of the member’s habits and treatments in real-time.

In 2019, we worked with a Fortune 50 health insurer to develop and build an educational chatbot on MedicareMadeClear.com. The chatbot sits on the Microsoft Bot Framework on Azure and leverages LUIS as the AI. In addition to development and QA, we helped create the decision trees and led UX and UI, copywriting, and accessibility direction for the chatbot user experience—all of which greatly impacted member engagement.

What goes into designing an effective AI program?

Strategic direction:

In order to have a successful artificial intelligence program, insurers must first complete a current-state technology assessment. In our experience working with Fortune 50 health insurers, a fundamental initial step in any type of technology implementation or migration is the understanding of where one is and where one needs to get to. Through an audit, insurers can first understand and map out the technology solutions they have in-house and what, if any, they need to purchase or outsource to reach future-state objectives.

Governance:

Having a solid governance foundation is another vital component to ensuring a successful AI solution implementation. Because artificial intelligence is a relatively new solution set, the insurer will need to work with and engage its human resources team in creating and hiring for roles that could be new to the organization (data scientists, AI solution architects, etc.). Once the personnel involved in the program have been identified both internally and externally (vendors), it is imperative to have roles defined and a review cadence in place to assess implementation progress.

What are some of the biggest keys to AI success for insurers?

When it comes to artificial intelligence, one of the first things that can cause apprehension is the notion of replacing human resources. Insurers can better educate their employees about what AI brings to the organization in relation to new job opportunities and career growth. By mapping out the white space that this ever-evolving technology creates for their workforce, insurers can alleviate employee concerns about job security and demonstrate where and what those career opportunities might be. Insurers should also seek to educate themselves on the various components of artificial intelligence and how the solution set can grow over time so that they can better understand what is achievable now versus in the future.

As artificial intelligence continues down the path of future growth and adoption, approaches to operations will undergo many changes. Fundamentally, success for the healthcare industry will depend upon how quickly it can identify and capitalize on these new technologies and solutions—embracing them for the win-win they are for both patients and insurers.

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File Under
  • COVID-19
  • Engagement
  • Health
  • Technology