AI Offerings

Responsibly Unleash the Power of AI

At healthplans.ai, we deliver comprehensive AI Health Plan solutions that span the health plan ecosystem.

Health plans can utilize a single AI solution for a specific process or multiple AI solutions for various functions. These can be considered independently or packaged together. Leverage the power of healthplans.ai solutions trained with our 25 years of deep domain health plans experience.

Not sure where to start? Begin with a healthplans.ai Discovery AI Solution. This AI tool uncovers deep operational and process bottlenecks by analyzing business processes and their associated tasks. It is an essential first step in identifying the AI-powered services that can provide the best operational efficiency, performance impact, and cost savings.

AI Technology-Enabled Solutions for Health Plans

Our core AI technology-enabled services span the front, middle, and back office, providing non-invasive tools that enable health plans to capture intricate details about any operational process.

Health Plan Business Operations

Our Health Plan Business Operations services encompass enrollment, claims, customer experience, and sales and marketing.

  • The enrollment process involves several critical steps, including managing paper applications, addressing the reject queue, and handling requests for additional information. These requests must be meticulously recorded, with responses sent through various channels, such as letters and calls, within specific timeframes. Here’s how our AI enabled solutions streamline the enrollment process:

    1. Application Submission: AI solutions manage the application submission processes and protocols, ensuring accuracy and efficiency.

    2. Enrollment Guidance: AI guidance solutions help members sign up efficiently and accurately, reducing internal service requests and increasing customer satisfaction.

    3. Rejections and Information Requests: AI solutions handle rejections and requests for additional information from members, facilitating timely and detailed responses.

    4. Agreement Ratification and Fulfillment: AI solutions assist in ratifying member agreements and engaging with fulfillment processes.

    5. Enrollment Application Processing: AI processing solutions streamline the entire back-office enrollment workflow, connecting disparate systems together and reducing tedious, manual bottlenecks.

  • An AI-driven approach ensures that each step of the claims process is optimized for efficiency and accuracy, from initial data validation to final payment integrity. Our comprehensive AI-enabled claims automation solutions cover several critical aspects. Additionally, our AI-enabled solutions implement cost containment strategies to control and reduce costs associated with claims:

    1. Pended Claims Management: AI solutions categorize and route claims based on complexity and determine what approval and denials are needed or should be addressed further. 

    2. Claim Data Management, Validation and Verification: AI solutions provide upfront validation and verification of claims data to ensure accuracy and completeness, streamline the management of claims data throughout the process, and offer human-in-loop end step validation.

    3. Claims Guidance: AI solutions guide claims processors across claims management, providing training and real-time question and response.

    4. Payment Integrity: AI solutions ensure the integrity of payments through rigorous checks and balances. These include ongoing checks for policy and regulations updates from CMS and more.

    5. Provider Data Management: Utilizing AI solutions to manage provider data effectively and ensure accuracy of provider databases.

  • Every member and provider interaction is handled with precision and care through our AI-driven approach, providing a superior customer experience. Customer experiences solutions leverage advanced technologies to enhance support and streamline interactions:

    1. AI-Enabled Helpdesk: AI continuously analyze data to identify high propensity calls and improve service offerings. These intelligent chatbot solutions handle a variety of tasks, including prior authorization and eligibility of benefits, providing quick and accurate responses to customer inquiries.

    2. Voice and Linguistic Analysis: AI solutions utilize voice and linguistic analysis to improve our Interactive Voice Response (IVR) systems and call trees, ensuring efficient call triage and better customer service.

    3. Call Triage: AI solutions can detect and analyze incoming calls to identify high-priority issues and route them appropriately with a sophisticated call triage AI-enabled solution.

    4. Collateral Management: AI solutions intelligently monitor communication channels, ingest incoming collateral, and classify, route, and trigger process-specific workflows.

  • Tailored solutions enhance your sales and marketing efforts, ensuring seamless operations designed to drive engagement and support diverse communities:

    1. Campaign Management: Uses AI for comprehensive campaign management services to effectively plan, execute, and analyze marketing campaigns. Analyze marketing campaign performance in real-time, making automated adjustments to optimize ROI and reach.

    2. Multilingual Operational Support: Breaks language barriers by providing multilingual support across operations, customer service, and marketing documentation. Enhances global accessibility and helps create localized marketing content e.g. Chinese (Mandarin), Japanese, and more. 

    3. Underwriting Support: AI solutions offer robust and secure underwriting support to curate vast amounts of data and ensure accurate risk assessment and policy issuance.

Health Plan Administrative Operations

Our Health Plan Administrative services cover essential areas such as finance, human resources, and IT.

  • Our AI solutions help health plans manage their finances efficiently, providing the tools needed for accurate financial planning and analysis. Comprehensive financial solutions include:

    1. Finance AI Agent: Automates accounts payable processes, improving budgeting and cash forecasting, and facilitating timely financial close. Achieves 100% accuracy in invoice validation and reduces processing time by 70%.

    2. Regulatory Compliance Verifier: Uses AI to verify customer agreements against policy requirements, ensuring all regulatory standards are met, reducing risk and improving accuracy.

    3. Fraud Detection and Prevention Agent: AI solutions provide real-time monitoring and verification of transactions to identify and mitigate risks, protecting health plans from financial fraud.

    4. Automated Reconciliation Agent: AI solutions streamline the reconciliation process across multiple financial accounts, flagging discrepancies for human review and ensuring accuracy.

    5. Financial Forecasting AI: Analyzes historical data and market trends, providing accurate financial forecasts and scenario analysis.

  • AI enabled solutions to provide the tools needed to manage HR functions effectively, ensuring a productive and engaged workforce. These Human Resources solutions encompass a range of services designed to optimize HR operations:

    1. Employee Training GenAI Walkthroughs: AI solutions create walkthroughs to train and guide users in completing tasks across multiple applications and processes. Reconciles support to a single source of truth, leveraging SME and internal business documents.

    2. HR Admin AI Solution: Supports and responds to all HR queries and process automation requirements such as leave management, policy inquiries, and attendance tracking. Facilitates knowledge sharing and improves employee engagement.

    3. AI-Powered Talent Acquisition: Automates resume screening, candidate matching, and initial interview scheduling, improving the efficiency of the recruitment process.

    4. Employee Sentiment Analyzer: AI solutions monitor and analyze employee feedback and communication to gauge overall workplace sentiment and identify areas for improvement.

    5. Performance Management AI: Assists in setting, tracking, and evaluating employee performance goals, providing data-driven insights for performance reviews and development plans.

  • An AI-driven approach helps manage and resolve IT tasks effectively, ensuring compliance and improving overall operational efficiency. These IT solutions are designed to streamline operations and enhance efficiency for health plans:

    1. Help Desk Management: AI solutions help efficiently manage IT help desk operations to resolve technical issues promptly.

    2. Resource Onboarding and Termination: AI solutions automate the onboarding and termination processes, including access management, enhance security and compliance to ensure seamless transitions.

    3. Ticket Creation and Management: Utilize AI solutions from any method (email, chat etc.) to create and manage support tickets, ensuring timely resolution of issues.

    4. Mailroom and Return Mail Management: AI solutions digitize, and scan return mailed, using OCR to match with member records and push to a work queue for accurate and efficient resolution and address any compliance issues.

Health Plan Data Analytics and Dashboards

Our Health Plan Business Operations services will help you deliver more manageable costs, deeper member and provider engagement, and better health outcomes.

  • With advanced analytics and dashboards, health plans can gain a deeper understanding of their data and make more informed decisions. Data analytics and dashboard solutions provide comprehensive insights by integrating data from various sources, including voice, portals, and more. This approach delivers:

    1. Needle-in-the-Haystack Analytics: AI-driven analytics can sift through vast amounts of data to identify critical insights and trends.

    2. 360° View: AI solutions offer a holistic view of data, providing detailed descriptive insights into specific groups, individuals, or plans and predicting future trends.

    3. Multi-Source Integration: By combining data from multiple sources, AI enabled solutions ensure a complete and accurate analysis leveraging descriptive, predictive and prescriptive analyst.

    4. Actionable Insights: Dashboards present data in an intuitive format, enabling informed decision-making and strategic planning.