Health plans’ operations have historically been managed in silos, with each silo using different data. This has impeded efficiency and consistency for utilization management, payment integrity, member outreach, and other critical healthcare decision-making processes.
Clinically trained automation solutions that use AI hold exciting potential to connect those silos, make data interoperable, and transform some of payers’ most burdensome processes and workflows.
These were insights shared at Becker’s 4th Annual Spring Payer Issues Roundtable, during a session sponsored by Cohere Health, titled “Beyond automation: Optimizing siloed workflows with unified clinical AI.” The session was moderated by Matt Parker, chief product officer at Cohere Health, featuring Christian Corzine, RN, vice president, clinical services and operations, Medical Mutual and Abiah Loethen, senior vice president, analytics and clinical systems, AmeriHealth Caritas.
Here were three key takeaways from the session:
1. Cumbersome siloed workflows and data are a major pain point for both payers and providers
One of payers’ most painful, error-prone processes is utilization management (UM), which includes approving or denying prior authorization requests. This workflow — which requires navigating different silos and data — creates administrative burden and provider friction because lack of seamless interoperability leads to frequent delays and denials. “It is a really terrible process for our UM folks as well as providers,” Ms. Loethen said.
2. An intelligent clinical AI solution can streamline UM, other workflows, and member outreach
A clinically trained AI solution that unifies all clinical and administrative data and automates a significant portion of decision-making can transform legacy UM.
AmeriHealth has partnered with Cohere Health to implement its clinical intelligence platform to streamline clinical operations today–while laying the foundation for a more proactive, member-centered future. By unifying data, the platform not only improves operational efficiency and care access, but also surfaces insights into a member’s overall health needs. Looking ahead, AI-powered capabilities could enable plans to automatically identify and engage members with preventative or wraparound services tailored to their needs–reducing reliance on manual outreach and expanding how plans support members at scale.
Because most providers also don’t have access to patients’ holistic clinical and administrative records, health plans can be better partners by sharing those insights and helping orchestrate solutions. This could help improve insurers’ historically strained relationship with providers.
“Having access to the full clinical record drives full member care,” Ms. Corzine said. “You can look at the member holistically, have one point of contact, and follow them throughout their journey. It’s ironic to use AI to add more human touch, but that’s exactly what we’re doing.”
3. When assessing AI vendors, payers should consider several key characteristics
For multi-state health plans like AmeriHealth, it is important that a tech partner has the know-how to adapt AI tools for different state requirements.
Another major consideration is whether a vendor has capabilities to integrate with payers’ existing data and technology stacks to help design a seamless automation architecture. The more of those capabilities a single technology vendor has, the more compelling their offering can be, since having too many technology partners can result in the silos health plans are trying to eliminate.
Also, the ideal AI vendor is clinically rooted and has deep healthcare expertise, so they can understand health plans’ businesses and be good partners.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
