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Artificial Intelligence: Ready to Disrupt Health Claims Management

May 8, 2018

Have you ever had a medical claim processed incorrectly? Well, those days might soon be over, thanks to artificial intelligence.

Artificial intelligence, of course, has been around for a while, but there’s more buzz about it now because healthcare companies are beginning to arm themselves with the right algorithms, they have tons of data and, increasingly, they have the IT muscle to make it work.

While AI isn’t a magic bullet, it can spot trends and patterns that often go unnoticed by physicians and so it is helping to save lives.

For example, hospitals are using machine learning to help them detect the onset of life-threatening instances of sepsis in their patients. It’s helping public health officials predict the next epidemic as well as keep track of opioid hot spots. AI is also helping companies develop new drugs and vaccines. IBM Watson and Pfizer, for example, have teamed up to use AI to sift through reams of data, including more than 30 million lab and data reports.

Those are undoubtedly some of the more exciting developments on the AI front. But there’s also huge potential for AI in hospital claims management.

In a recent report, the business consultants at McKinsey noted that up to 10 percent of all claims received by insurers in Germany are wrong to one degree or another. AI, they said, can help fix that by identifying and even helping to correct bad claims. This could save insurers and providers alike a great deal of time, money and effort.

German health insurers alone could save about $600 million a year, McKinsey said.

There’s been plenty of hype over IA over the years, yet we might be at that proverbial tipping point.

McKinsey certainly thinks so. “The conventional approach to claims management based on an inflexible rule book has been made obsolete by intelligent algorithms that learn from historical cases and continuously evolve,” it said in its report.

“Obsolete?” Probably not quite yet. As any data scientist will tell you, AI and machine-learning systems cannot fulfill their potential without the right IT infrastructure in place or without the availability of high-quality data – a monumental and expensive job.

But AI is already disrupting healthcare as we know it, so it’s easy to imagine that insurers and large hospital owners will want to do what they can to get aboard the AI train, perhaps not tomorrow, but soon.

Scott McGraw is Vice President of CCIG’s Employee Benefits division. Reach him at 720-330-7924 or

CCIG is a Denver-area insurance brokerage with the full-service capabilities of a national brokerage. We do more than make sure you have the right policy. We also help you manage your long-term cost of insurance with our risk and claims management expertise and a commitment to service excellence.

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