Can Artificial Intelligence Be Used In Health Insurance?


  • With the increasing use of artificial intelligence (AI) in the medical sector, many practices in this sector are integral to it. Dependence of technology has led to many operations integral to AI.
  • With AI smoothening many operations in the medical sector, it is only a matter of time when its use increases in the healthcare insurance sector as this sector has already started incorporating AI in many activities.
  • Use of AI is already proving helpful in the call centers of health insurance companies. AI is being helpful in various process integration activities that were earlier believed to be unfeasible. Process integration via AI is time-saving. AI has also eased digital health analytics.
  • Experiments to check for what more can AI be used only shows that in health insurance, the use of AI is only going to increase the way it is increasing in the rest of medical sector.
  • There are programs that can automate day-to-day tasks.

In the recent years, the use of artificial intelligence (AI) has not only increased in the medical sector, there are some operations dependent on technology that are now integral to AI. The use of AI in the medical sector started with creating, updating and saving electronic health records (EHR). Medical records of a patient helps doctor to understand his/her medical history, and check if the patient is allergic to certain medicine or medical treatment. These insights help doctor to plan a customized medical treatment for the patient.

Key Uses Of Artificial Intelligence In Medical Sector

Apart from EHR, the major healthcare activities in which artificial intelligence is useful include disease diagnosis, drug interactions, imaging, radiology, and telehealth (going beyond telemedicine). AI is also helpful in the manufacturing of new drugs. Automation of various medical procedures via AI has reduced time to execute them and thus, now things are easy for doctors.

With AI in use for so many healthcare operations, it should not come as a surprise if health insurance also embraces AI.

Beginning Of Artificial Intelligence Use In Healthcare Insurance

Healthcare employees who work as nurses, call center agents, often use artificial intelligence to help patients schedule appointment with doctors. Those working as assistants of doctors often write reports on the basis findings from AI that operates any medical software.

According to some media reports, a health insurance company called Humana has become the first company in USA to incorporate AI in its operations and other health insurance companies are likely to follow the suit in the near future. When it comes to insurance, one employee of the insurance company has to serve many clients.

With 45,000 associates of health insurer Humana serving over 14 million members, the use of AI is required as human error cannot be allowed here. They are using AI and robotic processes to make their tasks easy and faster. Many times, if a client has problem in accessing the online data, associates guide him via demonstration enabled by AI to help him/her understand the data access procedure. Alexis Paul, director of intelligent and robotic process automation says:

“Humana made a conscious decision to use digital innovation to help our associates deliver a better healthcare experience our members.”

Using AI In Call Centers

There are few primary reasons under which people call the call center of an insurance company. Such reasons include appealing a medical coverage decision, inquiry about benefits eligibility, understanding a claim status, or placing orders for new or re-filled prescriptions.

To reduce the workload of call center employees or automate the process so that company would have to hire less employees, the artificial intelligence can be brought into play. The answers to frequently asked questions can be stored in different information systems. Using AI and intelligent automation, the health insurance company can bridge gaps between systems which can improve coordination between systems and ensure a better call experience for the caller. Alexis Paul says:

“Whether a member calls about their medication or claim, we have a bot, or what we call ‘digital worker’ actively helping the associate serve the member during the call. We are able to answer the question so much more quickly”.

Process Integration Via AI

What Humana is doing today is something that every health insurance company would be doing very soon. Because efforts are being made to bring together different components of machine learning (ML) and automation that are already available into a single tool.  In this regard, the statement from Alexis Paul is as follows:

“Humana’s use of natural language processing, machine learning and robotic process automation allows their associates to have information instantly at their fingertips across multiple systems.”

Integration of one process with many business functions and systems can be turned into one experience via artificial intelligence. Hence, now if a call operator is handling claim process, he/she can handle many parts of the member’s request without transferring a call.

Many times, callers with appeal requests for denied service can give a hard time to the call operator. For example, callers with grievances and appeals want immediate action or change. To address these concerns, the health insurance company can deploy cognitive digital workers to improve the process for routing requests that are associated with the initial grievance and appeals call. This helps call center employees to make better and faster decisions.

A cognitive digital worker is defined as a digital worker that uses ML to present options to the call operator beyond just automating a repetitive task.

Experiments For Smarter Solutions

All health insurance companies must be eyeing on the possible results as Humana has revealed that it is experimenting with sentiment analysis and natural language processing to see if these technologies can be used to analyze the transcripts from appeals calls.

From the members who have purchased insurance policies from Humana in past, the company is learning the specific vocabulary model, patterns and sentiment, to make their softwares smarter before they are integrated with artificial intelligence.

The success of these experiments can widen the scope for not only more creative solutions but also for smarter ML-based solutions to the clients of Health Insurance Company. These solutions can be drawn from past case history.

Result Automation Fast Tracked

Many companies have a dedicated task force for the processes demanding intelligent and robotic process automation. This task force uses artificial intelligence, intelligent automation, and natural language processing to automate the cross functional and independent desktop processes. Many companies in banking sector and general insurance sector are already doing this and in health insurance sector, Humana has started it.

Many companies prefer to use Automation Anywhere for their desktop automation service and Workfusion to power their intelligent automation software.

Automation Anywhere can automate many repetitive swivel-chair tasks in the organization. This enables all the constant work employees do to pull data off one screen and key it in another. It also allows the business units and business teams to write their own screen automations rather than needing to burden IT team. WorkFusion can use natural language processing to automate tasks with unstructured data. Unstructured data is defined as any textual data that comes from a paper document or electronic document such as a PDF file or email message. Talking about Humana using Automation Anywhere and WorkFusion, Alexis Paul said:

“How does one extract information and make decisions on messy fax forms and on medical records which arrive in a thousand different formats? We use the natural language processing and machine learning capabilities of the WorkFusion tool to make this happen. We treat automation like a product with every product having a purpose and life cycle.”

Paul said that Humana implemented innovation on the desktop years ago with two helper apps. This made it seamless for an employee to sign on and share information across multiple systems. Humana still uses those desktop apps as well as several other apps that are being developed and deployed by Humana itself.

AI Use For Digital Health & Analytics

Digital Health & Analytics team helps automation team when the latter needs solutions-specific healthcare data analytics, algorithms, or creative digital experiences. Digital Health & Analytics team serves the purpose of bringing together agile development, analytics capability, and consumer design. This facilitates data scientists to concentrate on digital enablement as well as digital transformation.

Using natural language processing, along with artificial intelligence, the Digital Health & Analytics team produces insights on data.  It also provides outputs and trends to the automation team so that the team can augment the robotic process automations. Over time, the types of implementable cognitive automation tasks can be expanded and moved beyond with regards to information extraction and classification.

Building Citizen Developers

Encouraging its employees to be citizen developers, Humana has started a new trend which other health insurance companies are going to follow soon. A citizen developer is defined as a new term that is used to describe non-programmers who use artificial intelligence and automation tools to build programs. Kerry Wang, intelligent automation center of excellence leader, says:

“When we kicked off automation three years ago, we made a conscious effort to select tools that our associates could use to automate the redundant, boring tasks in their work. We identify and train those associates who want to be citizen-developers.”

A citizen developer program launched by the automation center of excellence taskforce uses Automation Anywhere to allow health insurance company employees to identify and automate simple day-to-day tasks. The purpose of this program is to provide code reviews, training, and guidance on automation. This reduces the workload of IT team as now the employees of Health Insurance Company do not need to depend on IT team for every automation activity.

Future Plan Of Action Regarding AI Use In Health Insurance

We discussed six activities for which artificial intelligence is necessary for health insurance sector. That explains the importance of AI in this sector. A health insurance company wishing to use AI needs to ensure that training, supervision, and maintenance of their digital workers mirrors that of their human employees.  The push to decentralize decisions to their employees can deliver meaningful results for the company.

The investment in the right digital set up is crucial the development, advancement and upgrade of AI. In the context of Humana, Alexie Paul said:

“People who were doing mundane repeatable tasks before now have become a manager of the  digital workers, managing teams and generating exponentially more throughput than they could alone. Behind the scenes, Humana has a significant platform of people, software, and processes enabling artificial intelligence and automation to succeed.”

Paul also said that automation and digital health & analytics could deliver a better healthcare experience.

Benefits AI Use In Health Insurance

The use of artificial intelligence in health insurance sector is cost-effective. It is also secure as it can be helpful for fraud detection. The machine learning algorithms that are capable of detecting fraud are not science fiction. Such algorithms actually exist. Fraud in insurance claims has been an old practice and health insurance is no exception.

Therefore, the use of AI is not only feasible in health insurance, it is also need of the hour. AI-equipped technology is the future and the future is here.