Claims Management's Next Frontier Is Data-Driven Claims Revolution

November 1st, 2024

Human empathy still needed

By Melinda Young

The future of claims management will be in the hands of technology, including artificial intelligence (AI) as cost-effective, efficient technological strategies rise to the forefront of the industry.

“This is just the beginning of the process, which leads to some of the biggest changes we can expect,” says Raja Sundaram, MS, MBA, chief executive officer of Plethy, an Insurtech and health tech company, in San Jose, CA. Sundaram spoke on the topic of health information laws and care transitions at the 2024 Case Management Society of America Conference in Providence, RI.

“People have always looked at healthcare in the context of the right care at the right time, and I look at it as the right care, right time, right cost,” he says.

Data telemetry gives the healthcare industry an opportunity to personalize care and determine the right amount of services at the right time, he adds.

“What we’re beginning to see is the start of a new era of claims management, one that is supported by rapid technology advancements and a growing amount of data,” Sundaram explains. “What this does is it lets all these insurers use a combination of automation and human empathy to reach the outcomes they want, and it's all because of data.”

Technology now available in claims management includes these three parts:

Claims process automation: Every time someone uses a claims management platform to connect with other entities, there is an opportunity to get better data and visibility into the claims process, Sundaram says. “It also gives you the opportunity to have microservices, which are particular pieces of a process and have the ability to automate. We manually used to review every bill that came in. Microservices take care of these bills, make sure they’re valid, and then pay for it.”

Adoption of new technologies: Each technological advancement is new once. One advancement that is making its way in the claims management arena is the premise of cloud computing. “From a technology standpoint, it enables a horizontal software plan,” Sundaram says.

Connected partner ecosystem: “One of the challenges we’ve always had was that a disparate group of providers were not [always] interconnected,” he explains. “Now, you may have the physician, nurse case manager, physical therapist, and all are interconnected through the electronic medical record.”

When various providers are connected, they can view the patient holistically. They form a partner ecosystem of providers. Associated services like utilization review are also more connected now than previously.

Using AI and medical wearable devices are part of the future is part of the solution for helping case management improve chronic disease management and patient self-care. The next technological phase involves a biopsychosocial approach that was not possible previously, Sundaram says.

It is evolving in a claims management landscape in which the workforce is changing.

“Look at the changing skills of the claims management workforce,” he says. “We gravitate to thinking that everything that is going to be obsolete by automation, but, no, it’s not.”

What AI and other advanced technological solutions currently lack is human empathy.

“You’ll [need] the right size of empathy, but also the right analytical and digital skills,” Sundaram explains. “It’s a person connecting with the technology.”

Empathy comes from the human claims handler, who is at the center of the ecosystem, he adds.

“They are this connection between different actors and the actual patient,” he says. “The question is not whether AI can do all of it, but rather it’s about what we’re comfortable with AI playing that role for us.”

The world is becoming a little more comfortable with AI, the crawling stage of it. The next stage is walking and then running, Sundaram says.

“The walk phase is where we’re feeling comfortable with AI interaction with the patient, and we’re tagging the human as needed,” he explains. “The run phase is about AI playing all of these roles. The question for us is on the run phase. Are we as humans comfortable with AI doing that? Do we trust AI to not have bias?”

The answer is that AI could have as much bias as society has because its code is developed by humans with inherent biases, although that’s not going to be true indefinitely, he says.

“What you're seeing in the marketplace is a lot of really good, synthetic data that gives us for the first time an opportunity to stay off these biases,” Sundaram says. “So the models are learning from unbiased, synthetic data.”

Achieving this ideal will be challenging, and there remains a necessary human element: “The human element is empathy,” he says.