At the Fall 2025 Becker’s Payer Issues Roundtable, industry leaders explored how clinical intelligence and digital transformation are redefining the payer-provider relationship.
The session, titled “From Policy to Payment: Clinical Intelligence Driving Health Plan Innovation,” featured Andrea Willis, MD, senior vice president and chief medical officer at BlueCross® BlueShield® of Tennessee, and Carmen Thomas, assistant vice president of operations at BlueCross BlueShield of South Carolina. The discussion centered on how health plans are applying data, AI, and clinically informed decision-making to modernize policy management, streamline operations, and improve care outcomes–highlighting the shift toward a more collaborative payer-provider experience.
Here are four key takeaways from the conversation:
Note: Quotes have been edited for length and clarity.
1. Aligning policy and provider experience is key to transformation
Payers are rethinking prior authorization not as a gatekeeping tool but as an opportunity for provider collaboration and clinical alignment.
“The goal is getting to ‘yes’ a lot quicker through evidence-based practice,” Dr. Willis said, emphasizing that timely, transparent decision-making supports both quality and efficiency while keeping member needs at the center of every decision.
Both panelists stressed the importance of making clinical guidelines transparent and usable at the point of care. At BlueCross BlueShield of South Carolina, digital prior authorization tools powered by Cohere Health have driven a leap in digital provider adoption — from under 10% to over 85% in-state — and cut turnaround times by nearly half, according to Ms. Thomas.
2. Digital nudges for smarter submissions
Intelligent systems are giving providers real-time prompts — or “nudges” — about missing or incorrect information before an authorization request is reviewed. “The interaction becomes almost like they’re speaking to a nurse,” Ms. Thomas said. “It’s evidence-based, policy-based, and benefit-based.”
3. Prior auth is becoming a strategic data signal
Rather than treating prior authorization as a siloed process, both health plans are leveraging it as an early alert system to improve outreach, case management, and cost forecasting.
At BlueCross BlueShield of South Carolina, digital platforms help identify members for early intervention and trigger proactive member engagement around upcoming treatments, according to Ms. Thomas.
4. AI is reshaping operations — but human judgment is still key
Both executives underscored that AI is never used to make denial decisions at their plans, but rather to streamline clinical reviews and support staff.
“It’s not AI for the sake of AI — it’s ‘how do we make things better?’” Dr. Willis said.
Ms. Thomas shared how early trust-building — having nurses manually validate every AI-assisted decision — laid the groundwork for broader adoption. Looking ahead, BlueCross BlueShield of South Carolina is exploring AI use for improving denial letter readability and aligning claims submissions with clinical documentation.
Both leaders agreed that by 2026, success will be measured not just in efficiency but in how these tools expand quality programs and member education. “Education and transparency are most effective when they begin with the provider and are thoughtfully cascaded down to the patient,” Dr. Willis said. “Empowering patients with clear information helps foster trust and supports better health outcomes.”
BlueCross BlueShield of Tennessee and BlueCross BlueShield of South Carolina are independent licensees of the Blue Cross Blue Shield Association.
