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How Health Plans Harness Artificial Intelligence

by Darcy Lewis

November 30, 2016

When it comes to artificial intelligence (AI), health plans are poised to use science fiction-like technologies to improve consumers’ experiences and streamline their businesses. Some health plans have already ventured into AI.

Here’s a peek at what’s happening now and what lies ahead with AI in health insurance.

Meet Humana’s AI Bot

What if you could call your health plan’s customer service center, knowing that the customer service agent taking your call could receive instant coaching while working to resolve your issue?

For Humana plan members, that is happening already.

Humana is using AI to identify challenging member experiences in real-time with the help of its AI bot, Cogito Dialog, FierceHealthPayer reports. “As members call in to its customer service centers, Humana’s AI tool listens for signals of caller frustration.”

When it detects these signs, the bot delivers instant feedback for the customer service agent to reassess his or her approach, given the high amount of sensitivity and empathy needed to resolve issues regarding sensitive subjects like medications and medical procedures.

The technology builds on the first generation of AI bots that were trained to identify key words but couldn’t easily improve relations between customer service agents and members, Fierce reports.

Anthem explores Big Data

Meanwhile, Anthem is investigating new ways of using its internal data to assess and improve its interactions with members and health care providers. According to Deloitte, Anthem has hired data scientists with experience in the retail sector to offer insights into the way consumers make decisions about their health care.

Anthem offers a variety of individualized wellness programs, notes Deloitte, which are supported by a sophisticated mash-up of claim- and case-related information overlaid with “softer” consumer data.

Patrick McIntyre, Anthem’s senior vice president of health care analytics, has described big data as “the collection and use of data that we receive direct from members via call center interactions, our online portal, remote health monitoring devices, and other big data sources. Applied to medical, claim, customer service, and other master data, these tools are already delivering insights into members’ behaviors and attitudes.”

More innovations on the way

Relevant Anthem pilot programs include a tool to guide consumers through the company’s call centers to the appropriate level of service. Near-real time predictive models work in tandem with text mining and natural language processing applications to make it possible for Anthem to identify members with high levels of dissatisfaction, and proactively reach out to those members to resolve their issues, McIntyre told Deloitte.

Another pilot project uses analytics to identify members who have multiple health care providers and who have contacted Anthem’s call center several times. These calls trigger an automated process in which medical data from providers is aggregated and made available to call center reps, who can use this comprehensive information to answer these members’ questions more effectively.

Cambia Health subsidiary gets in on the act

GNS Healthcare, one of Cambia Health Solutions’ holdings, is a software company that develops personalized predictive models for hospitals. Its AI software predicts individual risk, causes of risk, and how likely individual patients will be to act on suggestions from their doctors.

GNS uses claims data, including medical, pharmacy and behavioral health, and also considers genomic data, socioeconomic metrics, and geography.

The company most recently partnered with Inova Translational Medicine Institute, a branch of Inova Fairfax Hospital, to develop software that can identify pregnant women at risk for premature births, Health Plan Week reports. Prematurity affects one in every nine babies, so the potential for protecting families and reducing health care costs is significant.

These examples show that health plan members may not even be aware when AI helps smooth interactions between themselves and their health plan, and that’s good. What matters most is improved communication – and better service.


Interested in the opportunities and challenges facing digital health technology today? Register for AHIP’s Consumer Experience & Digital Health Forum, Dec. 06 – 08.