By: Jeff Gutcheff, Vice President, EC Ops, CorVel
Generative AI will revolutionize claims administration in the next several years, transforming how insurance companies, third-party administrators, and medical management firms manage claims processing and settlements.
While some claims companies are already using discriminative AI, which focuses on identifying and classifying existing data patterns, generative AI is much more powerful. It goes beyond analysis and spotting patterns to create new content. It does this by using deep learning techniques such as neural networks to learn patterns from large datasets and generate new data that follow those patterns.
Here are 10 ways in which generative AI will transform claims management:
1. Distilling documents and flagging data points. Generative AI streamlines the claims process by summarizing all medical documents into claims notes, extracting keywords, answering specific questions about the document, and bringing items that might have been missed to the attention of the adjuster or nurse.
2. Automating claims processing. Generative AI learns from past claims and identifies new ones that match these patterns, automating processes that fall within specific parameters. Claims adjusters’ workloads are lightened, and claims are processed faster.
3. Improving fraud detection. Generative AI can identify potential fraud cases by spotting patterns and anomalies that may indicate potential fraud or abuse, such as prolonged claims with little or no improvement, excessive use of medical resources, or inconsistent injury complaints.
4. Enhancing communication. Chatbots can provide an overview of the claims process and keep all stakeholders up to date on benefit coverage, the progress of the claim and the treatment plan, and payment of invoices. These chatbots use natural language processing to respond to queries in a human-like manner, improving customer service and reducing the workload of claims administrators.
5. Personalizing customer service. These intelligent chatbots powered by AI algorithms can answer customer queries and provide support throughout the claims process. Using Generative AI to automate objective tasks will increase the amount of time adjusters spend interfacing directly with the injured workers will ultimately improve outcomes.
6. Enabling risk assessment and underwriting. Generative AI can analyze large amounts of data and identify patterns that will inform underwriters, helping them better understand risk factors and develop more accurate models.
7. Identifying patterns between claims. This capability allows the system to estimate the outcomes of a claim to similar, current claims; as a result, claims managers are better informed.
8. Mitigating employee turnover. As senior claims managers retire, generative AI can bridge the gap between their knowledge and experience and a workforce just starting their careers. It can also shorten the learning curve for new employees. For example, ChatGPT will make answers immediately available to statutory and regulatory questions, prior claims outcomes, and next steps. It will be like having a trained, senior level supervisor always available for coaching and mentoring.
9. Increasing employee satisfaction. Freed from spending countless hours analyzing data and reports to find problems and figure out what is next, employees can focus on helping injured workers – a role that is much more satisfying.
10. Empowering the human factor in helping injured workers get better. Combining the power of generative AI with human expertise means that claims adjusters make more accurate and informed decisions for each person and have the time to personally engage on meaningful issues. Every member of the claims and care teams can work at the top of their game.
Jeff Gurtcheff is the Vice President of Enterprise Comp Operations for CorVel Corporation.