Harish Pai 

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Consider a 30-year-old individual weighing 130 pounds, who exercises regularly and has no chronic ailments or insurance claims. Health insurance providers categorize him as “low risk.”  However, the following year, he gains 40 pounds, which now raise health concerns, and this makes him a “high-risk” patient. For this type of patient profile how can healthcare insurers provide a healthcare plan that is both relevant and competitively priced? At the same time, there is currently much uncertainty around affordable healthcare, driven by rising insurance payouts. So how can healthcare insurance organizations plan offerings that remain both competitively priced and realistic?


Today, the innovation that makes this possible is artificial intelligence (AI). AI has enabled new possibilities for healthcare plans and brought in improvements to the healthcare cycle.

Here are four ways AI is being leveraged in healthcare plans.

. As today’s healthcare systems are increasingly hyper-connected, there is more data at every stage. However, according to estimates, around 75% of the available healthcare data is unstructured. In managed healthcare, AI is enabling advanced analytics towards more effective prognosis. AI enables clinical data to be analyzed with a predictive analytics approach. It is also being extensively used to analyze electronic health records and glean insights for population health management by performing trend analyses and identifying health patterns. This provides insurance providers and payers with an understanding of patients’ health and future projections. AI plays a crucial role in defining and pricing insurance plans by identifying member populations based on medical history, age profiles, and geographically localized trends. Such data-driven population insights could, for instance, highlight the need for a payer to craft a completely different price plan for California as compared to Virginia.

. Whether it is fitness apps or devices, wearable technology enables the healthcare system to get an in-depth picture of an individual’s health and adopt preventative measures. Using the data from wearable technology, AI enables insurance payers to establish patterns of patient behavior, anticipate developments that an insurance plan should cover, and track the health of members to ensure customized plans and pricing.

. Earlier, it was complex and time-consuming to check if fraud was being committed in the claims process. Now AI can perform the crucial task of spotting patterns of abuse and analyzing fraud.

. For every interaction with a patient or member, AI can be used to provide a 360-degree understanding of the patient in a single view. Having such historical details framing the conversation can ensure a well-informed and meaningful interaction with useful takeaways. In addition, whether it is a conversation, a chat window, an audio call or video meeting, AI can also be used to detect the customer’s mood-whether the customer is, for instance, happy or agitated or tired, and how the healthcare organization should respond accordingly.

As healthcare organizations are increasingly embracing predictive analytics while emphasizing the security of patient data, IT is driving the adoption of AI, and enabling its implementation in tandem with technologies for big data, cloud, and blockchain.

Blockchain technology has a special role to play. First, it can ensure a high level of security for electronic health records as it can enable a seamless and secure sharing of patient health data within the patient’s discretion and control. Second, it can simplify revenue cycle processes, with examples being claim adjudication, billing management, improper billing and reimbursements, as the data is transparent. Such process simplification can go a long way in improving the overall business practices. Blockchain technology can solve the healthcare industry’s security problems and is the answer to the question of interoperability. The application of blockchain and AI in tandem strengthens the benefits they bring to the industry and the two can evolve together.

The quality and outcomes achieved far outweigh the costs of implementing these new technologies. Today, healthcare organizations are concerned with how to improve the cost of care with providers being incentivized on outcomes, instead of on the number of visits. While focusing on the quality of care and outcomes, costs get reduced through better forecasting, targeted treatment, timely care, and a preventative approach, thus contributing to improving the bottom-line of healthcare organizations. With this outcome-based approach, patients are also encouraged to lead better lifestyles. Furthermore, patients can now be targeted with specific information, and customized plans, instead of being served by a one-size-fits-all approach. This patient-centricity makes outcomes beneficial for patients, providers, and payers. This is why several payers are already partnering with healthcare organizations that use AI-led technology to drive population health management, identify patient risk scores, and plan pricing.

To start using AI, healthcare organizations can employ a staggered approach. A step-by-step method to adopting and applying AI and related technologies across the organization can provide a more measured view of the results and enable better control over costs.


AI will evolve, moving toward more personalized clinical care for patients, which will create a win-win scenario that benefits healthcare providers, insurance payers, and the patients. Most importantly, AI is enabling payers and providers to innovate in bringing healthcare plans to patients, and in competitively executing them, reimagining the patient care journey.

Harish Pai is a senior vice president and the chief technology officer for Business Technology Solutions at 

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Author | Harish Pai

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