By Cliff Belliveau, myMatrixx Chief Innovation Officer
For anyone watching, 2023 has undoubtedly been the year of Artificial Intelligence (AI). Although it has been used for years in fields ranging from finance to manufacturing to personal assistants such as Siri and Alexa, the public launch of ChatGPT by OpenAI last November marked a real turning point in the way society and business view this technology. ChatGPT, or generative pre-trained transformer, is a large language model (LLM) developed to provide detailed and articulate responses to nearly any question, and its incredibly human-like and knowledgeable answers have left many asking if the era of intelligent machines has arrived.
As this and similar applications have exploded in growth, a broader conversation has started into how AI and related subfields, including machine learning and predictive modeling, could potentially transform nearly every aspect of life. While AI likely won’t change everything overnight, there is every indication that the current $120 billion market will continue to grow. Some estimates have the global AI industry becoming as valuable as $1.6 trillion by 2030.
With a sizable portion of AI-activity likely to be directed into the health care and insurance fields, it is crucial for leaders, stakeholders, clinicians and claims professionals in workers’ compensation to understand this technology and the potential impact it will have on our sector. Specifically, in the area of care and management of injured patients, there are tremendous opportunities for AI-assisted technologies to improve patient and client experience, reduce fraud, waste, and abuse, streamline workflows, analyze medical data and create better outcomes through predictive modeling.
Amid industry concerns such as an aging workforce and labor shortage, AI brings unique opportunities for improving efficiency and quality of care for workers’ compensation organizations that can embrace innovation. In the first part of a two-part look at AI in workers’ compensation, we will examine some of the most exciting ways these advancements can shape the future of workers’ compensation. In part two, we will delve into the challenges and objections to adoption and the potential solutions that are out there.
1. Virtual Assistance Support for Claims Management
When dealing with a customer service request or issue, most people would rather speak to a live person than navigate an automated menu. Even a well-designed and helpful system is currently limited in the type and complexity of assistance it can provide.
With experienced claims professionals and clinicians being a limited resource – and often overworked – the ability to deliver an elevated level of service is a challenge that every organization faces. By combining machine learning, LLMs, speech recognition, and other technologies, the ability for an AI to deliver a level of support indistinguishable from a well-trained professional may not be far off.
Potential applications range from providing an additional layer of care for the treatment of injured patients to acting as an automated advisor for claims professionals. For example, with the proper training, an AI could learn to review an injured patient’s prescribed drug regimen, identify potential problems or errors and respond appropriately by chat or voice.
2. Reduction of Fraud Waste and Abuse at Large Scales
Fraud, waste, and abuse is a problem that costs the workers’ compensation insurance industry billions of dollars a year and puts lives at risk. To a well-trained eye, many of the signs of improper practices can be easy to detect. The problem is typically one of limited resources and scale – most companies don’t have the people and time to sift through large volumes of case files to connect the dots of bad activities.
With growing capabilities, AI is just beginning to match the ability of people to contextualize information and recognize the patterns required to counteract fraud and other harmful practices. Efforts are currently underway to train computers to identify unnecessary services to patients, improper provider billing and doctor shopping. Where AI offers tremendous possibility is its ability to work at large scales, reviewing entire datasets rapidly, flagging issues and potentially making recommendations for action.
3. Automated and Streamlined Workflows for Claims Professionals
Process automation is nothing new. For decades, IT departments have been working in nearly every industry to automate mundane and repetitive administrative tasks. A computer program taking five seconds to perform a basic function that would have taken a person a minute can save time, money and enable people to use their time and energy for tasks that are better suited for their abilities.
Where AI comes into this picture is once again scale and resources. In many situations, human programmers are only able to automate processes that have been identified and brought to their attention. Sometimes a department can go years doing something manually before someone notices an opportunity for automation, and even then, there can be limited resources for design and implementation.
By analyzing workflows and using predictive models to identify and forecast bottlenecks and inefficiencies, an AI could essentially be trained to automate the automation. This would not only free up resources for IT departments, but also streamline and lighten workloads for people in other lines of business, such as claims professionals. Having AI perform large-scale tasks that reduce the need for mundane and repetitive “button pushing” enables people to better focus on the jobs they are actually trained for and still require human capabilities.
4. Processing and Analyzing Medical Data
Medical data is one of the most promising untapped resources in all of health care. The growing body of health data has already led to substantial advances in the understanding of diseases, injuries and treatment; but there are obstacles preventing data scientists and clinicians from fully harnessing its power. One of the biggest hurdles is that much of this data is unstructured – meaning that it exists in raw forms such as medical documents and prescriptions.
In the same way that words need to be put together correctly to form meaningful language, unstructured medical data requires significant resources to process and analyze so it can be useful from a diagnostic or treatment standpoint. While much of the work required to process this data is relatively straightforward data processing, it is yet another situation where the sheer volume of work required currently surpasses the available labor.
Structuring and even analyzing large volumes of medical data is an area where deep learning models are beginning to reach a threshold of competency. From transcribing and documenting notes to analyzing rates of diagnoses in certain populations, AI could accomplish these mundane and repetitive tasks quickly and accurately. Making this vast wealth of data usable can also open the door for AI to better predict outcomes and improve treatment.
5. Predicting Outcomes and Improving Treatment Models
Machine learning and LLMs already have a staggering ability to process and analyze entire bodies of data and literature in a way that is meaningful to people. Similar to the role that education plays for people, training is critical to achieving high quality results from AI. In health care and in the workers’ compensation industry, a trained AI program with access to a library of structured and accurate data would be able to draw conclusions and predict outcomes in a way that surpasses our current ability.
This includes identifying and forecasting health risks based on populations, occupations and comorbidities, as well as predicting treatment length, cost and outcome. Not only would this mean less spending on unnecessary or ineffective treatment, but it could also drastically shorten the recovery and return to work periods while minimizing the risk of behavioral health issues and substance misuse. Across the treatment spectrum, physicians, pharmacists and other clinicians would be backed and assisted by powerful virtual colleagues who could amplify their current knowledge and abilities on a large scale.
From the standpoint of workloads, efficiency, quality of care, outcomes and cost savings, the workers’ compensation has every reason to adopt and leverage the power of AI. Like any other technology, there will be challenges and problems both foreseen and unforeseen that will emerge over the coming years. However, as we’ve seen with other technologies from automobiles to the internet, the benefits can be life changing.
In part two of this series, we’re going to take a closer look at some of the most common objections, challenges and misconceptions facing the adoption of AI in workers’ compensation. More importantly, we’ll discuss the solutions and ideas that can help us overcome these obstacles and enable us to fully harness this exciting technology.
About Cliff Belliveau
Cliff Belliveau is the Chief Innovation Officer for myMatrixx. He is responsible for leading the initiatives that enable automation, advanced data analytics and visualizations for internal and external stakeholders. Belliveau is an accomplished information technology leader with a track record of delivering solutions to complex business problems. He has over 25 years of experience in all facets of information technology – from managing high performance teams to systems architecture, application integration, software development, operations and support. He is also the inventor of two awarded patents.
He is a lifelong resident of Tampa and enjoys spending time with family, water sports, traveling and coaching youth athletics.
myMatrixx, an Evernorth company, offers best-in-class pharmacy services for workers’ compensation programs that include: formulary and network management, utilization management, claims processing, home delivery and specialty pharmacy care and physician outreach programs.
Working with the financial and risk management leaders of organizations, myMatrixx helps reduce the pharmacy cost associated with injured workers through innovative programs, business analytics and robust clinical protocols and expertise.
myMatrixx is committed to providing predictable pharmacy benefits management to get injured patients back to work and their lives safely.
myMatrixx is a WorkCompWire ad partner.
This is NOT a paid placement.