From Fragmentation to Innovation: The Role of AI Platforms in Modernizing Health Plans
As healthcare costs in the United States continue to surge, with projections reaching $7.7 trillion by 2032, health plans face mounting pressure to innovate and adapt. The industry's complex value chain, marked by regulatory challenges and the escalating need for operational efficiency, demands a transformative approach. A next-generation AI-driven platform isn’t just a solution—it’s the key to unlocking unprecedented value, transforming payment integrity, optimizing operations, and navigating the complexities of an evolving healthcare landscape.
The Power of Integrated AI-Based Solutions Delivered on an Integrated Platform
Implementing an AI-based platform starts with building bi-directional integrations and interoperability with both core internal and partner external systems. The data would be managed using modern data architectures and techniques; enabling the creation of shared datasets and the deployment of AI insights that amplify each other—pushing the boundaries of what health plans can achieve.
Moreover, single bi-directional integration with a claims system would allow for both the ingestion of claims data into the AI platform, and for the delivery of edited claims back into the adjudication cycle. The same ingested medical claims, that are used in the payment integrity editing solution would also be reused by AI models to generate clinical insights. These insights
could thereafter be shared with care teams via a platform integration with the care management system or through an integration with the provider’s electronic health records system; to further improve member clinical quality, risk adjustment, and population health management. In addition, a reporting solution would be deployed on the same platform and use the shared datasets available to quantify the cost of care savings attributed to both payment integrity and proactive care management solutions.
This platform approach and advanced AI models pave the way for unlocking greater value than ever before for payers across the following functions:
Payment Integrity: Health plans can shift more post-pay payment integrity functions to be performed pre-payment, reducing the need for costly recovery, while streamlining reporting, and ultimately lowering costs.
Claims Processing: Health plans can benefit through increasing their auto-adjudication rates, reducing overpayments, lessening penalties, and improving overall efficiency.
Prior Authorization: Streamlining this process would reduce administrative burden, reduce costs, drive greater efficiency, and improve both provider and member satisfaction.
Clinical Quality: Reimagining this process enables health plans to better identify and close care gaps in a timely manner and maximizes the window for intervention and proactive care management; critical for improving clinical quality, outcomes, and cost efficiency clinical insights.
Risk Adjustment: Optimizing risk adjustment processes would be a tremendous step forward to ensure the appropriate level of attention is given to health plan members, increasing the accuracy of provider reimbursements, and ensuring adequacy of funding or revenues to health plans.
Population Health Management: Transforming this process enables more accurate prioritization of member care, personalized interventions, and personalized clinical insights that would improve the effectiveness and impact of population whole health strategies.
Value-Based Care Enablement: Providing a more comprehensive view of the member, population health insights and measures, and seamlessly integrating them into the provider workflow, maximize collaboration and enable providers to be successful in alternative payment models and performance-based payment arrangements.
The AI platform would be extensible beyond the solution categories outlined above so health plans can maximize their investment in the platform and develop and deploy powerful solutions proprietary to them on it. Existing platform capabilities, data, and algorithms, tailored to specific needs, would be components that can be reused by these new solutions. New solutions can also leverage existing reporting capabilities to publish reports to enterprise stakeholders. Data and insights generated by new solutions can also be integrated into existing enterprise reports and systems by reusing platform integrations.
This approach would improve health plan technical and business operations, and reduce implementation risk, time, cost, and complexity. It would improve data and information quality and strengthen information security. It would also provide a highly efficient cost-consciousness technology infrastructure and lower the total cost of ownership of the portfolio of solutions deployed by a health plan.
Unlocking Value Beyond Cost Savings
While reducing healthcare costs is a primary goal, next-generation AI platforms will offer value that extends far beyond mere savings - enabling health plans to transform their operations and relationships in multiple ways.
By streamlining processes and reducing administrative burden, AI platforms can significantly improve payer-provider relationships, reducing the friction that often characterizes these interactions. This reduction in provider abrasion would catalyze more effective collaboration, greater stakeholder alignment, drive greater affordability for plan members and patients, and ultimately greater quality of care.
AI-driven insights and personalized interventions are not just tools—they are true drivers that revolutionize member outcomes, paving the way for a new era of proactive, precision healthcare and deeper collaboration with providers. These platforms can analyze vast amounts of data to identify potential health risks and recommend tailored interventions, ultimately driving better health outcomes for plan members.
The benefits extend to the overall customer experience as well. Improved efficiency and personalized care contribute to higher member satisfaction. Members can receive more timely and relevant communications, easier access to care, easier to understand costs and billing, and a sense that their health plan is proactively working to improve their health.
Perhaps most importantly, these platforms enable a shift—in mindset and action—towards proactive care. By predicting health risks and recommending interventions before issues escalate, AI platforms can help health plans move away from the more costly and traditionally reactive model of healthcare. This proactive approach not only improves health outcomes but can also significantly reduce costs associated with emergency care and advanced disease states.
Next-generation AI platforms are not just cost-saving tools but lay the foundation for an effective suite of comprehensive solutions that can revolutionize how health plans operate and deliver value to their members and provider partners.
Real-World Impact
The potential of AI-driven platforms is already being demonstrated in real-world applications. For instance, an AI solution deployed in 17 dialysis centers to predict hospitalizations and missed treatments resulted in improved treatment planning and an estimated $100 per member per year in savings. When scaled across all facilities, this could translate to $250 million in annual savings – a testament to the transformative power of AI in healthcare.
Overcoming Implementation Challenges
While the benefits of AI-driven platforms are clear, health plans must navigate several challenges to successfully implement these solutions:
Data Integration: Combining diverse data sources into a cohesive platform can be complex, requiring robust healthcare-specific data management and interoperability capabilities.
Staff Resistance: Change management strategies are crucial to overcome resistance from staff asked to adopt new technologies and processes.
Trade Partner Adoption: Health plans must provide incentives and education to encourage providers and other partners to embrace these new solutions.
Operational Excellence: Implementing new technologies without compromising key business performance metrics or regulatory compliance requires careful planning and execution.
Regulatory Navigation: AI platforms must be designed to help health plans meet evolving regulatory requirements, such as the CMS interoperability mandate for government-sponsored plans.
Embracing a Platform-Centric Mindset
To remain competitive in the rapidly changing healthcare landscape, health plan leaders must adopt a platform that addresses healthcare interoperability, integrates with various vendors and solutions in the ecosystem, and offers healthcare-specific data models and AI-based solutions. Such a platform, using cutting-edge technology while allowing for extensibility, would enable health plans to build their own powerful solutions on top of the platform, to meet relevant and costly challenges.
These platforms must also strive to establish a comprehensive longitudinal record of member health, needs, and preferences, powering customizable AI solutions that drive innovation, improve efficiency, reduce costs, and enhance member experiences. These platforms should also be built using cloud-based technology for security, reliability, performance, scalability, and cost efficiency, while ensuring healthcare interoperability for seamless data interaction.
As health plans navigate the complex healthcare landscape, AI-driven platforms offer a promising path forward. By leveraging these advanced technologies, health plans can not only address rising costs but also transform their operations, improve care quality, and enhance member satisfaction. While the path forward presents challenges, the rewards—both in transformative cost efficiencies and groundbreaking health outcomes—make embracing AI-driven platforms not just an option, but an imperative for the future of healthcare.
The future of healthcare demands bold leadership, driven by a commitment to innovation and a willingness to challenge the status quo. By adopting AI-driven platforms today, health plans can not only navigate the complexities of tomorrow but also set the standard for excellence in a rapidly evolving industry.
About Lyric
Lyric, formerly ClaimsXten, is a leading AI healthcare technology company, committed to simplifying the business of care. Over 30 years of experience, dedicated, expert teams, and top technologies help deliver up to $14 billion of annual savings to our many loyal and valued customers—including 9 of the top 10 payers across the country. Lyric’s solutions leverage the power of machine learning, AI, and predictive analytics to empower health plan payers with pathways to increased accuracy and efficiency, while maximizing value and savings. Lyric is investing in AI driven technology to ease implementation and speed to value for customer savings, while offering enhanced and newly available solutions through internal product development and strategic partnerships, including recently announced partnerships with Concert Genetics, Autonomize AI, and now, Codoxo. Discover more at Lyric.ai.
