6 ways AI will transform health plan operations and the member experience

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Health plans can improve member communications, increase efficiencies, allow for more personalization and reduce the healthcare spending by implementing AI into your operations. It also allows for real-tine transparency which allows for faster claims and payments and a more accurate risk assessment.

Healthcare is among the top two or three industries where AI’s impacts will be most transformative — from improving clinical outcomes and expanding access to care, to dramatically enhancing patient experiences and, perhaps most critically, rewriting paradigms around cost-effectiveness of care delivery. AI uses cases among healthcare providers have already gotten plenty of attention, but some of the most powerful benefits will stem from AI applications within the health plans space: Research from early 2024 estimated that growing adoption of AI among healthcare payors could drive a 5-10% reduction U.S. healthcare spending — amounting to $200-$360 billion annually.

Here are six tangible ways that health plans are already using AI to drive key outcomes:

1)     Faster claims processing

AI will dramatically improve both the speed and accuracy of claims processing. Claims processing while simultaneously lifting accuracy. AI algorithms enable fully automated claims processing, analyzing claims in seconds for faster claims settlement, while all but eliminating the errors inherent in manual claims processing. AI can also enable real-time transparency to keep members information on the status of claims for better member experiences. Faster claims settlement and faster reimbursements enhance member satisfaction, improve relationships between payors and providers, and help to reduce plan liability for late claim payments. Also, automated claims processing allows staff to shift focus from repetitive claims analysis tasks to value-added work elsewhere in the claims processing workflow.

2)     Smarter fraud detection

AI will play a key role in reducing healthcare fraud that costs the U.S. roughly $30 billion every year. AI tools can more broadly identify patterns indicative of fraud, including machine learning models that analyze historical examples of fraud to glean common characteristics and enable predictive fraud scoring. Because AI can be deployed to analyze every claim in real time, payors can detect fraud earlier and prevent or mitigate much of the cost.

3)     More accurate underwriting & personalized risk assessment

AI enables payors to move toward personalized and predictive health risk assessments. Predictive modeling can more reliably anticipate an individual’s health risks, analyzing individual health data, lifestyle, and other factors at a much more granular level — and doing it at scale for all members. This allows for more precise underwriting that optimizes business performance down the line for the payor organization.

Jon Chu – Chief Product Officer Toppan Merrill

“AI is revolutionizing healthcare by automating claims processing, enhancing fraud detection, and delivering personalized health insights, driving efficiencies and improving patient experiences. At Toppan Merrill, we’re listening to our customers and integrating AI into their workflows, leveraging our expertise in document management and content creation. This innovation empowers us to create a more responsive and proactive digital platform, leading to better outcomes for everyone.” Jon Chu – Chief Product Officer, Toppan Merrill

4)     Predictive health interventions & proactive health management

AI allows health insurance organizations to shift from reactive illness management to proactive health management, centered on predictive health interventions. By analyzing both population health data at a broad level and individual health data at a granular level, AI can identify at-risk individuals and prescriptively suggest preventive measures. AI can also assist in chronic care management, monitoring patient data in real time and providing instant alerts and actionable interventional recommendations to both patients and providers. These predictive and proactive insights will significantly reduce costs of care in the best possible way: by empowering providers to keep patients healthier.

5)     Improved operational efficiency

AI will automate many of the routine administrative tasks for health insurers, allowing them to both accelerate key workflows and reallocate resources to drive business value in other important ways. Process automation allows AI to handle basic data entry, policy renewals and compliance checks. AI’s impacts on member support will drive tremendous efficiencies. AI chatbots can handle routing inquiries in real time, 24/7 — providing coverage details, claim status and policy information. More responsive support will not only improve member satisfaction and retention, but by some estimates will drive as much as a 40% reduction in member service costs.

6)     Better member experiences

In addition to the instantly responsive support provided by AI-powered chatbots, AI tools will enable human staff to deliver more personalized and proactive support to members. On the front end, AI systems can analyze individual health data and historical claims to provide health insurance plan recommendations tailored to best fit that individual’s unique health and lifestyle needs. On an ongoing basis, AI can fuel more proactive and prescriptive member communications, including reminders for preventive care, follow-up appointments, medication refills, etc. AI can also consider real-time data from remote health monitoring devices (i.e., wearables) to trigger personalized care recommendations and reminders that help increase adherence to treatment plans. All of this adds up to delivering a member experience that feels like a personal health assistant dedicated to each unique member.

How Toppan Merrill can help health plans

Toppan Merrill helps MAOs prepare their annual member-facing and marketing materials each year, so your sales force and membership have the resources they need. From document creation and management, sales enablement, omnichannel communications, printing services, and more, we deliver best-in-class solutions that help you respond quickly to changes in regulations, member needs, and markets.

Learn more about how Toppan Merrill can help with your health plans member communications.

Jen Trewick - Principal Product Manager

With more than 20 years of industry expertise, Jen Trewick brings a wealth of product management expertise to her work on solutions for Health Plans. She previously led an advanced team of industry experts focused on dynamic publishing for companies offering Medicare Advantage plans, to ensure they met CMS member communication compliance requirements through leading technology solutions.

Jen Trewick - Principal Product Manager's Photo

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