How Alaffia Health is Using AI to Streamline Health Plan Operations

Since the beginning of this year, generative AI has dominated conversations among consumers, corporations, and government agencies alike. And for good reason—the capabilities of large language models, as illustrated by ChatGPT’s debut in November 2022, have had a notable impact on various industries, including media, education, and law, to name just a few. But for many technology enthusiasts, it's the potential impact within healthcare that sparks the most excitement.

As noted by TJ Ademiluyi, CEO of Alaffia Health, a healthcare technology company that builds AI solutions to help health plans reduce their healthcare spending, “Given the sheer size of the industry, mass adoption of generative AI in healthcare would yield unprecedented monetary benefits for all patients. It’s the silver bullet we need to finally start bending the cost curve.” 

Healthcare spending amounts to over $4 trillion each year in the US. According to JAMA, a staggering 30% of that spending may be wasteful, stemming from ineffective care delivery, administrative complexities, billing fraud, and more—costs incurred by both providers and payors. Collectively, health systems and health plans face a complex web of regulations, administrative burden, and limited interoperability, key complexities exacerbated by unstructured and non-standardized siloed data. Navigating this labyrinth is no easy feat, but the team at Alaffia Health believes that next-generation AI models will redefine how we approach these challenges, setting a new benchmark for healthcare innovation and delivery.

The company builds AI-powered solutions to help payors reduce their healthcare spending, securing its clients 8 figures in claim savings over the last 12 months alone. At the helm of Alaffia Health's innovative approach is its flagship generative AI assistant, Ask Autodor, purpose-built to streamline health plan operations. The AI tool is revolutionizing the way health plans review, analyze, and adjudicate claims:

Streamlining Complex Claim Reviews

Health plans can leverage Ask Autodor to decrease unnecessary healthcare spending by streamlining claim reviews and mitigating improper payments. The AI assistant highlights the most pertinent areas of the patient's medical history, diagnoses, and treatments, allowing clinicians to quickly identify and address any areas of concern. With Ask Autodor, clinicians can review complex facility claims within a matter of minutes accelerating a process that, depending on the complexity of the claim, could take several hours to complete.

Optimizing Medical Necessity Determinations

Whether for prior authorization requests, payment integrity, or contract compliance, determining medical necessity for services is a costly task for health insurance plans. Ask Autodor supports clinicians by helping assess whether a requested or provided service aligns with clinical guidelines and criteria. The AI assistant offers insights and direct feedback on the appropriateness of procedures, length of stay, and more, allowing health plans to finalize their reviews up to twenty times faster.

Seamless Integration

Ask Autodor integrates into existing claims systems and workflows, allowing health plans to seamlessly embed the solution into their existing operation and workflows. Purpose-built for knowledge workers across claim operations, staff across risk adjustment, utilization management, and payment integrity can quickly onboard and begin to extract value from the AI assistant.

Alaffia Health remains dedicated to its efforts to build best-in-class AI solutions to streamline processes and reduce wasteful spending across the ecosystem. While the company sees various use cases for generative AI in the future, today it remains focused on ensuring health plans most timely and accurately reimburse healthcare providers for their services. Each order of magnitude of efficiency gained through the adoption of advanced AI tools has the potential to eliminate billions of dollars in costs across the healthcare ecosystem.

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