When Katerina Guerraz, Aetna’s COO, stepped into her role in mid-2024, the company was having, by her own admission, a really tough year. Rather than look for incremental fixes, she and her team decided to set a new direction entirely — one focused on fundamentally redesigning how Aetna operates, not just for the company, but for the providers and members it serves.
“We completely need a different north star — figure out how do we work differently with providers, how do we really design around the member experience, and then where can, how fast can we accelerate and apply technology for automation, and just have more smart workflows and streamline the work, not just for our constituents, but also for our colleagues,” Ms. Guerraz told Becker’s. “That’s the big difference — how you apply this, so it actually makes the healthcare system better, simpler, and you take a lot of the friction out.”
The result is a sweeping operational push tackling claims processing, workforce training, provider relationships and member navigation — all connected by a single goal: taking friction out of the healthcare system.
The push for real-time claims
One of the most visible moves has been Aetna’s second-generation claims assistant, designed to reduce the manual work that has long slowed claims processing and frustrated providers. It’s a development Ms. Guerraz couldn’t have predicted.
“In my 30 years of healthcare — I actually started in clinical trials — I would never have thought we would be doing announcements on claims,” Ms. Guerraz said. “But the reason that we did is because we’re excited about it. If you think about health insurance and healthcare, there’s still a lot of advancements that have happened, but not necessarily in the way of operations.”
The vision is straightforward: providers get accurate claims paid faster and members stop receiving explanation of benefits documents that don’t make sense. But the longer-term north star is even more ambitious. At Aetna’s first annual provider forum last year, attended by representatives from the top 30 health systems, Ms. Guerraz made a commitment that real-time payment needs to become the industry standard.
“I didn’t give a timeframe, but I said we need to get to a place in healthcare where we’re doing real-time payment,” Ms. Guerraz said. “Because when we eliminate rework, it’s better for everyone – members, providers, and the healthcare system overall.”
AI fluency for every colleague
Aetna currently handles 19 million provider calls a year. The goal is to go upstream — anticipating needs and surfacing information proactively so that many of those calls never need to happen in the first place.
Alongside the technology investments, Aetna has launched an AI Academy across Aetna and CVS Health, designed to bring every colleague up to a baseline level of AI fluency — not just those in technical roles.
“When we think about the future, AI isn’t about taking people’s jobs — it’s about augmenting people, the work that people do, and it’s going to transform how people do their jobs and how we have to upskill them,” Ms. Guerraz said. “Our point of view in our company is that there is a basic level of AI that our colleagues are going to need, whether it’s on the job or outside in their homes and in other parts of their lives.”
The academy has been paired with operational deployments — including AI tools for Aetna’s more than 15,000 nurses that pull information from multiple systems and summarize it before member calls. The feedback from staff was overwhelmingly positive, though it came with an important message about pace.
“They said to us, ‘These tools are great, but think about the pace, because there’s only so much we can absorb. We’ve done the AI Academy, you’re launching these new tools, making our jobs easier so we can actually spend more time with people instead of just handwriting notes all the time,'” Ms. Guerraz said. “So I think that’s where we’ve been listening — we have to pace this in a way that the workforce is using it at the top of their license.”
Pacing the workforce through change
Aetna has also mapped out what its workforce will look like two to three years from now, identifying which roles AI will augment and planning accordingly. One commitment remains firm: anyone who wants to speak to a human will always have that option.
“We have AI agents who are helping proactively solve issues and answer basic questions, but anyone who calls that number will always have the opportunity to talk to someone,” Ms. Guerraz said. “That’s not something that’s going away.”
Aetna’s provider survey reinforced what many in the industry already suspected — administrative ease remains the top priority. But the COO said there was also a more optimistic signal in the data that she didn’t want to overlook.
“I think generally the health systems and the providers in the survey who participated recognize that it is different now — we need to figure out how the system works differently and better together,” Ms. Guerraz said. “There’s a lot of openness to do things differently from a clinical collaboration point of view.”
One area that has gained traction is discharge planning. Aetna’s clinical collaboration program, now live in roughly 24 facilities, places nurses on-site at hospitals to help coordinate transitions and ensure members understand what benefits and services are available to them — work she said providers have genuinely welcomed.
“It isn’t the doctor’s job to educate a member on their benefits,” Ms. Guerraz said. “But we are working collectively to say, ‘Hey, the right thing is for this individual not to have to get readmitted and to get healthier.'”
Interoperability surfaced repeatedly in the survey as the most stubborn unresolved challenge — and she was direct about why it matters so much.
“I think interoperability is a big hiccup in the system – it creates a lot of friction,” Ms. Guerraz said. “Once we can get the data connected seamlessly, patients will be able to access care faster and it will make for a better overall patient experience.”
Removing the homework
On the member side, Aetna’s focus has been on what the COO describes as removing the homework — the burden members carry when trying to figure out what’s covered, where to go and how to get there.
“Our job is not just to take the member out of the middle, but also get rid of and remove the homework that a lot of patients and members have when they’re trying to figure out, do I have this benefit covered, where do I go for this,” Ms. Guerraz said. “All the tools that we’ve been rolling out right now are focused on navigation — we want to take the homework out where we’re proactively connecting information to members.”
Intelligent matching is one example, using Aetna’s data to connect members with physicians who not only match their language preferences and location, but who are demonstrably seeing new patients — not just listed as available in a directory.
“When people are trying to get an appointment with their primary care physician, they have to wait 30 days in some cases. If it’s a specialist, they have to wait months,” Ms. Guerraz said. “We hear from members — we do a lot of listening — and they’ll say, well, your directory says that this doctor is seeing new patients, but we can’t get an appointment for six months. Well, that’s why we’re doing this.”
The behavioral health gap
For behavioral health, Ms. Guerraz was candid that access — not coverage — remains the core challenge, and that the fragmented nature of the behavioral health provider market makes it uniquely difficult to solve.
“The biggest challenge is access,” Ms. Guerraz said. “People have a very tough time getting access to and understanding, how much coverage do I have. And I think the biggest piece that’s going to transform that in the rest of healthcare is when we get to a point where we’re seamlessly exchanging data with providers — that’s what’s going to transform it, because that’s a big hiccup in the system.”
To help bridge the gap in the near term, Aetna launched Mental Health on Demand this year — a virtual triage service that can provide members with real-time access to a licensed clinician through chat, phone, or video via the Aetna website.
“It may not be the specialist you need long term, but at least it triages you to talk to a mental health expert, someone with a clinical background, to help facilitate where’s the right place you need to go,” Ms. Guerraz said. “I think that’s very unique to behavioral health in this country.”
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