Health plans were early adopters of AI, using it to streamline claims processing, support call centers and manage utilization. Now, they’re ramping up AI deployment to enhance member experience, improve care quality and reduce administrative costs, according to America’s Health Insurance Plans, the national trade group for the insurance industry.
UnitedHealth Group alone has more than 1,000 AI use cases, including transcription tools and automated claims review, according to The Wall Street Journal. The company expects AI to handle more than half of consumer calls by the end of year. Other health plans, including SCAN Health Plan and Elevance Health, are also embedding AI into contact center operations.
“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden to improve the focus on patient care,” Conner Coles, director of public affairs a AHIP, said in a statement provided to Becker’s. “As adoption grows, strong industry standards and balanced national policies are critical to foster innovation while ensuring safety and trust for patients, providers and other health care stakeholders.”
Providers, on the other hand, are still catching up on AI adoption as they seek to address rising denial rates and administrative burdens. Many health systems have expressed concern that payer-driven AI tools are increasing friction in the payer-provider relationship rather than easing it.
Where health plans are using AI now
According to AHIP, health plans are deploying AI across a range of functions designed to improve member experience, clinical outcomes and operational efficiency. Common use cases include:
- Member support and customer service. AI-powered tools help health plans deliver faster, more accurate responses to benefit questions and often power plan apps that include pricing estimates and coverage guidance.
- Identifying care gaps and safety issues. AI-powered analytics help plans spot when patients miss recommended screenings or when their care may benefit from intervention.
- Predictive risk modeling. AI is used to forecast health risks, enabling earlier care management, targeted outreach and disease prevention efforts.
- Research support. Health plans are using AI to analyze disease pathways and treatment outcomes, helping inform coverage decisions and care management strategies.
- Administrative simplification. From claims processing to prior authorization workflows, AI reduces manual work and accelerates routine administrative tasks.
- Payment integrity and fraud detection. AI analyzes claims data to identify unusual billing patterns, enabling plans to work proactively with providers to reduce waste and prevent fraud.
As these use cases expand, AHIP says the objective remains consistent: improving value and outcomes while maintaining rigorous oversight.
“Health plans are embracing AI’s benefits while remaining committed to appropriate governance, monitoring and safeguards to prevent unintended consequences,” Mr. Coles said in a statement to Becker’s.
Prior authorization, AI and human oversight
Prior authorization remains one of the most sensitive applications of AI. AHIP maintains that while AI can help accelerate prior authorization reviews and approvals, it is not used to automatically deny requests based solely on algorithmic decision-making. When clinical factors contribute to a denial, a licensed clinician reviews the request, the organization said.
In June, many plans announced voluntary commitments to streamline prior authorization, increase transparency and encourage broader use of electronic prior authorization. AHIP says those efforts lay the foundation for responsible AI integration that could reduce delays, lower administrative burden for providers and improve patient access.
“The healthcare system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” AHIP President and CEO Mike Tuffin said in a June 23 news release. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”
Nearly 50 participating payers have committed to implementing a standardized electronic prior authorization submission process, with the goal of being operational by Jan. 1, 2027. The industry is targeting at least 80% of electronic prior authorization approvals to be issued in real time by 2027, with individual plans committing to specific prior authorization reductions beginning Jan. 1, 2026.
By combining electronic prior authorization frameworks with AI, health plans believe they can improve safety, reduce unnecessary friction and provide faster, more reliable care authorization processes.
Coding, claims and billing integrity
Health plans are also using AI to address persistent challenges around coding and billing, particularly as providers increasingly adopt AI-assisted clinical documentation tools that may influence coding levels.
Some states are also pushing back against unchecked AI use in claims processing. For example, a new bill introduced in New Hampshire would ban insurers from using AI to override providers’ clinical coding judgments and require transparency in how AI tools are deployed in claims audits.
While clinicians remain responsible for selecting and submitting billing codes, payers say AI can help flag potential discrepancies between documentation and billed services. To support payment integrity, many insurers are:
- Conducting targeted, data-driven reviews to validate that billed evaluation and management levels align with service complexity.
- Educating providers — via bulletins, documentation guidelines and training — to align with coding standards.
- Using public payer benchmarks, such as Medicare comparative billing reports, to identify potential cost inflation.
From the payer perspective, these efforts are designed to protect purchasers, members and public programs while maintaining trust with provider partners.
Governance, safeguards and what comes next
For plan executives — and industry groups such as AHIP — the goal isn’t simply to adopt AI for efficiency’s sake. It’s to do so responsibly. That includes maintaining human oversight for clinical decisions, aligning with regulators and developing transparent standards that balance innovation with patient safety and privacy.
“Health plans are embracing AI’s benefits while remaining committed to appropriate governance, monitoring and safeguards to prevent unintended consequences,” AHIP said in a statement to Becker’s.
As AI capabilities advance, plans expect to expand into more sophisticated applications, including real-time care coordination, advanced fraud detection and personalized member engagement. But AHIP emphasizes that progress depends on alignment among payers, providers, regulators and patients.
For payers, AI is more than a cost-containment tool: it is a catalyst for broader system transformation. The challenge is not whether to adopt AI, but how to deploy it responsibly, with accountability and trust at the center.
