Payers are harnessing AI to enhance data utilization

Despite the abundance of data in healthcare, its potential remains untapped due to ineffective processing, experts say.

The pharma market and payer market both face significant – and similar – challenges, particularly when it comes to managing vast amounts of data. They struggle with data overload, operational inefficiencies, identifying high-risk patients, and healthcare costs, among others.

“We all know that in healthcare, there is an overwhelming amount of data that unfortunately is not being processed very effectively,” Cheryl Roche-Alexander, principle at Enlightened Consulting, said at the recent Copay, Reimbursement and Access Congress. “And this data offers a lot of opportunity to drive longitudinal patient journeys and to understand where we can intervene and improve patient outcomes.”

Meanwhile, Indrani Halder, president of Fortuna Solutions, said the industry is “data rich but insights poor,” – a running joke among data organizations, she noted.

“That means we haven’t fully explored and investigated all the data that we have to drive the insights that we all are expecting to make our working lives easier,” she said.

Recognizing the challenges across the industry are universal, both Roche-Alexander and Halder agreed that artificial intelligence (AI) can help.

“AI offers the opportunity of better utilizing data, aggregating data, obtaining those insights and really focusing on how we can improve the patient experience, outcomes, and also population health,” said Roche-Alexander.

Patient engagement is also a focus where AI and machine learning (ML) show potential, she pointed out, through utilizing chatbots and AI avatars that engage with patients, provide education, implement care plans, and improve medication adherence. Roche-Alexander shared a statistic that 60% of patients never fill a prescription.

“If we can utilize these chatbots to interact and engage patients and consumers to drive better care in chronic condition management and make it even fun using gamification, for example, you can see that there’s an opportunity to really improve overall health within our country and shift to a more wellness versus a sick care healthcare system ecosystem,” she said.

How payer organizations are using AI

Focusing on payer organizations, Halder listed key areas of operations where AI is leveraged:

• Claims automation – AI streamlines claim processing while reducing fraud

• Risk stratification – AI identifies high-risk patients for proactive care management

• Utilizing management – AI expediates checking for necessity and automates prior authorization

• Network optimization – AI optimizes network based on provider performance and member outcomes

• Social determinants of health – AI identifies and helps solve gaps in transportation, food, and shelter needs

• PBM – AI optimizes drug pricing, formulary placement, and copay alignment

According to Halder, claims automation is one of primary focus right now among payers because the process is manual. “Unless those claims are properly adjudicated and paid, none of the stakeholders really realize their value. So significant efforts are underway,” she said.

Halder further explained how payment integrity is part of the business that deals with the majority of how claims are administered and how fraud, waste, and abuse are detected and intervened. She cited Elevance Health as the first to market with an AI-enabled payment integrity system as an example.

Another area of insight Halder emphasized from her list are pharmaceutical benefit managers within payer organizations (PBMs) and the ways they are leveraging AI.

“The focus really has been on using different data points to optimize drug pricing from a payer perspective. How do you figure out formulary placements? By taking a lot of different sources of data and figuring out who the patient is clinically,” she said, for example where they sit in the social determinants scale or what their preferences are.

“At the end of the day, we have vast amounts of data, and the goal is to identify patterns and trends.”

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