How AI is Impacting Health Insurance
Artificial intelligence is changing and transforming industries worldwide, and health insurance is no exception. For both insurers and the insured, AI has become a great time-saving resource. From streamlining administrative tasks to enhancing customer service, AI technologies are increasing provider efficiency and improving the experience for policyholders.
However, many are concerned with AI use in healthcare. Does AI have a place in health insurance, and when should it be used? This blog explores key ways AI is shaping the future of health insurance and the pros and cons of its use in the industry.
Pros of AI in Health Insurance
Though not everyone would agree, there are a few ways that AI is improving the Health Insurance industry.
Predictive health insights
One of the biggest strengths of AI is its ability to process large amounts of data. By analyzing health records, Artificial Intelligence can quickly categorize information and predict outcomes. This allows it to evaluate your health history, lifestyle and demographic information to pinpoint risk factors. In doing so, your doctor has a starting overview of your health and can provide higher quality care. Predictive health insights also allow for:
- Quicker diagnosis and treatments: If a doctor knows what you are at risk for, conditions can be caught quicker. Often, the sooner an illness or condition is detected, the more successful the treatments or even its prevention.
- Personalized Health Recommendation: AI allows your doctor to make recommendations specific to your health concerns. For example, if your family history shows frequent heart disease, your doctor can recommend habits and signs to watch for.
This personalization improves health outcomes by promoting proactive healthcare. Working in tandem with doctors, AI can improve your quality of care.
Improved Customer Service
One of the biggest pain-points in healthcare has always been long wait times and poor customer service. AI significantly improve these processes. Sure, it can be frustrating to talk to an AI rather than a real person. However, in most cases, AI is used to qualify or assess the urgency of your situation. This means you get to the right people the first time, instead of being transferred. It also helps more urgent cases receive care more quickly. AI is improving customer service though:
- Online chatbots: Telehealth is becoming an increasingly bigger tool for patients and providers. However, telehealth appointments previously bogged healthcare providers down. With online chatbots, AI can answer frequently-asked questions, sometimes helping the patient without need for a doctor. Chatbots also provide assistance 24/7, which doctors are unable to do themselves.
- AI Phone Answering Machine: Years ago, calling into your insurance provider could often lead to upwards of 30 minutes of waiting. Once connected, you would then have to be transferred to the department that would help you. Today, you are often greeted immediately by an AI. After a few questions, artificial intelligence is able to connect you to the right team for you. Any questions you have about claims, care or your policy can be answered in minutes.
For insurers, AI-driven customer service reduces operational costs while maintaining a high level of service quality.
Faster, more efficient processes
AI removes many bottlenecks from internal health insurance processes. By handling repetitive tasks and large datasets, artificial intelligence makes processes much faster. Overall, AI reduces errors, minimizes processing costs, and improves response times.
Fraud Detection and Prevention
Insurance fraud is a significant challenge, costing billions of dollars annually. AI combats fraud by:
- Analyzing Anomalous Patterns: Algorithms spot unusual activity that may indicate fraudulent behavior, such as exaggerated claims or duplicate submissions.
- Monitoring Social Media and Public Data: Advanced tools cross-reference claims with external information to identify potential discrepancies.
- Image and Document Analysis: AI can verify the authenticity of submitted documents and medical records using image recognition technology to detect forgeries or manipulated content.
By continuously learning from data, AI systems improve their fraud detection capabilities over time. It is becoming increasingly difficult for fraudulent activities to go unnoticed. These innovations lead to cost savings for insurers and help maintain lower premiums for honest policyholders.
Cons of AI in Health Insurance
While AI can do a lot of good, it is far from perfect. There are many areas where a human touch is needed for accuracy and honesty.
Inappropriate claim denials
By far one of the hottest topics in AI claim processing is its accuracy in denying claims. Since its implementation, hospitals are reporting more denials from insurance companies. In addition, doctors are claiming that they are often being overwritten on their determination of medical necessity. AI lacks context and operates off of an algorithm. This algorithm can be biased, basing its decisions based off of the data it is trained from. According to the American Hospital Association, claim denials have increased by more than 20% over the last 5 years.
accountability concerns
In the event of an error made by AI, who is responsible? It is important that the correct people are held responsible for medical errors. Such errors can have significant impact on the lives of those they affect. Without accountability, we cannot expect things to improve.
Bias and accuracy concerns
AI operates based off of data it learns from. In cases where data was not sufficient enough, AI can react unfairly or inaccurately. In some cases where old displayed bias, it is possible for AI to learn that bias as well. These things can result in unequal claim denial rates, poor quality of care, and more.
Is AI to Blame For My Claim Denial?
There are many factors that are taken into consideration for a medical claim. Whether or not it is approved can depend on you and your doctors more than the AI.
- Is the care you’re receiving covered? Most health plans have limits or exclusions in coverage. If the medical service you’re seeking is listed as an exclusion, your claim will be denied. Services like cosmetic procedures or elective treatments are typically excluded, though your plan may have other exclusions as well. It’s crucial to review what’s excluded before seeking care.
- You received care outside the network. Many health plans, including Medicare Advantage plans, partner with specific healthcare providers within a network. Care received from providers outside this network may not be covered by your insurance. In some cases, it may still be covered, but at much higher costs.
- Your claim was incomplete or inaccurate. Even small errors, such as a misspelling of your name, can lead to claim denials. If your claim is denied, reach out to your provider. They can review and correct any mistakes in your claim.
Conclusion: The Future of AI in Health Insurance
AI is reshaping the health insurance industry by driving efficiency, personalization, and improved fraud detection. As AI continues to see use across the world, we want to see it used correctly.
If you’re interested in learning more about innovative insurance solutions, contact our team at Health Plan Advocates for expert guidance. Or, skip the line and give us a call instead!
