Key Takeaways

One of my favorite parts of working at Memora Health is speaking with chief medical officers and clinical operations leaders at health plans. We talk about strategies for engaging members, care management programs designed to support individuals with chronic conditions, and some of the hurdles payors face in delivering high-quality, cost-effective care for complex populations.

Getting a member to engage with their health plan is difficult, but organizations are progressively adopting new ways of communicating with members through innovation. Payors are increasingly going beyond traditional channels and seeking to provide a more dynamic member experience. 

But how do we create a more personalized, high-touch member experience without increasing the workload for the health plan?

Forward-thinking health plans have demonstrated that providing members with a best-in-class experience can be achieved by increasing the efficiency of care management operations and related functions. New technologies like AI can reduce administrative burden and simplify workflows for care managers.

To harness the power of innovative technology, it’s helpful to understand how AI is used across the health plan industry and how intelligent care enablement can take care management to a new level.

How are payors starting to use AI?

AI has made a big splash in 2023. With over 80% of healthcare executives considering AI solutions and many evaluating how to leverage the technology to automate processes, payors have an opportunity to apply AI to increase efficiency and improve member engagement. Leading health plans are already using AI to improve operations, including:

1. Predictive analytics

Health plans are increasingly leveraging AI to identify members who are at high risk of developing chronic conditions. An estimated six in 10 adults have a chronic disease in the U.S, and that number is expected to rise over the next several years by most estimates. By analyzing data from medical records, lifestyle information, and demographics, AI algorithms can detect early signs of diseases like diabetes, cardiovascular issues, and cancer. 

This application of AI demonstrates how health plans are using technology to target members when there is still opportunity to slow the progression of chronic disease, which in turn improves outcomes and reduces total cost of care.

2. Claims processing and fraud detection

The time-intensive and error-prone nature of claims processing is being streamlined through AI-driven automation. AI algorithms can review claims for accuracy and flag inconsistencies or potential fraud. 

This approach accelerates the timeline for claims processing and helps prevent fraud, which can save health plans substantial financial resources. One analysis by the National Health Care Anti-Fraud Association suggests that total costs due to fraud could amount to $300 billion annually. By intelligently automating these processes, health plans can allocate resources more efficiently and improve payment accuracy. 

3. Accelerated prior authorizations

AI is helping health plans optimize the prior authorization process. By drawing on data to inform approvals, AI can automate administrative processes that previously took hours to complete. In fact, Health Care Service Corporation, which operates Blue Cross Blue Shield affiliates in Illinois, Texas, Oklahoma, Montana and New Mexico, expanded its use of AI to make prior authorizations 1,400x faster.  

This capability enables health plans to streamline administrative processes and allocate more time for team members to focus on higher-value work. 

4. Using AI to improve customer service

Conversational AI is helping to create efficiencies for member call centers and better anticipate member needs. Unlike traditional interactive voice response, this technology uses large language models to understand caller questions at an unprecedented level. 

In fact, one such application of conversational AI yielded a 90-95% sentence accuracy, effectively handling inquiries about benefits, claims, authorizations, and referrals without human intervention. This type of innovation could help health plans reduce costs while giving care managers more time to focus on the most complex member requests.

How AI can increase the scale and effectiveness of care management 

Novel applications of AI have the potential to enhance care management operations. Specifically, intelligent care enablement — scalable technology that supports both members and care managers through complex clinical episodes to more efficiently deliver personalized, proactive, and coordinated care — presents an opportunity for payors to improve outcomes and reduce total cost of care. Health plans can use this innovative technology to:

Memora Health’s intelligent care enablement platform boasts a member satisfaction rate of over 90%. Learn more here.

1. Educate members on the importance of primary care

A recent JAMA cohort study of over 500,000 continuously enrolled Medicare fee-for-service beneficiaries found that “having regularly scheduled visits to the same primary care clinician was associated with higher savings. The greatest savings were associated with higher frequencies [of primary care visits] as patient complexity increased.”

Intelligent care enablement platforms like Memora Health use AI to proactively engage members and improve access to  primary care through SMS text messaging. This means prompting individuals to select a PCP and schedule their Annual Wellness Visits, educating them about the importance of preventive steps specific to their personal care needs, and following up with them after screenings or consultations to answer questions or concerns. 

This technology automates outreach to members at scale via SMS text and provides care managers with more time to follow up with individuals who require hands-on support. AI supports care managers by handling manual and routine tasks, from conducting member outreach to collecting member-reported data to documenting member interactions.

2. Increase participation in care management programs

Readmissions cost an average of $15,200 per visit. To help avoid this cost and to improve the member experience, the majority of health plans have a Transitions of Care program to support members after discharge from the hospital or emergency department. Blinded data from one health insurer found only 20% of members eligible for Transitions of Care support were identified, 15% were successfully reached by care managers via telephonic outreach, and only 6% actually benefited from the care manager outreach.

Memora’s digital healthcare platform uses AI-supported SMS texting to meet members where they are and reach them more effectively. One study found that 98% of all text messages are read, and 77% of respondents said they engaged with text messaging more than any other phone application. 

With SMS texting, Memora helps payors meaningfully increase the number of individuals who participate in care management initiatives like Transitions of Care and Disease Management programs. Memora Health intelligently supports care management in a way that’s highly accessible for members and more streamlined for care managers.

3. Understand SDoH and help address barriers to care

The obstacles members face in their healthcare experiences often go beyond the purview of  our healthcare system. According to the American College of Physicians, key barriers to care include financial hurdles, lack of transportation, food insecurity, and insufficient health literacy. 

Hence, supporting members to address their needs takes a granular and personalized understanding of what specific challenges they face. Memora Health’s intelligent care enablement technology uses automation to send members screenings and surveys to identify what barriers they face and catalogs those interactions in a care manager-facing dashboard. 

Importantly, our platform uses AI to interpret responses and surface relevant resources for members, such as information about financial assistance programs, transportation options to attend appointments or fill prescriptions, and disease specific education. 

The era of AI in healthcare isn’t coming tomorrow. It’s here today. With payors increasingly exploring innovative technologies for improving care management, leaders in the market are evaluating and piloting solutions that holistically support experiences for both members and care managers. By embracing intelligent care enablement, health plans can effectively deliver a personalized member experience and scale care management programs.

Ready to see how intelligent care enablement technology can improve care management for your members? Speak with one of our experts!