Kevin Nolan Kevin Nolan

How AI works, and why it’s a game changer for health plans

In a previous blog post, we defined what AI is. But how does it actually work in healthcare?

The Short Answer: It Learns from Data

AI looks at massive amounts of information—claims, medical records, billing data, member engagement—and finds meaningful patterns faster than any human ever could.

What AI Can Do for Health Plans:

  • Spot fraudulent claims by flagging unusual billing patterns

  • Predict health risks based on member history

  • Flag care gaps when preventive services are missing

  • Segment members for more personalized outreach

And that’s just the beginning.

AI in Action:

  • Proactive Payment Review: Catch errors early, maintain compliance, and reduce waste.

  • Provider Performance Monitoring: Identify top performers and areas for improvement.

  • Enrollment Simplification: Automate data collection and verification.

  • Member Outreach: Deliver the right message, to the right person, at the right time.

This is more than technology—it’s smart, scalable problem-solving.

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Kevin Nolan Kevin Nolan

What is AI, really? A simple guide for health plans

Artificial Intelligence (AI) may sound like science fiction—but it’s already part of your everyday life. From the voice assistant on your phone to fraud detection systems at your bank, AI helps us work smarter, faster, and more efficiently.

But what does that mean for health plans?

Let’s break it down.

What Is Artificial Intelligence?

AI is the science of building machines and software that can “think” and learn like humans. It uses data, algorithms, and computing power to spot patterns, make decisions, and even take action.

In healthcare, this means:

  • Detecting fraud

  • Predicting health risks

  • Personalizing care

  • Proactive Payment reviews

  • Assessing Provider Performance

  • Optimizing Network Management

  • Simplifying enrollment processes

  • Enhancing Member Outreach and many more

What Are AI Agents?

One of the most exciting innovations in AI is the AI agent—a digital teammate that does more than just respond to commands.

AI agents can:

  • Goal Driven Behavior

  • Plan and prioritize tasks

·        Multi-step planning and decision-making

  • Make decisions based on context

·        Continuous learning and self-correction

  • Coordinate with humans, systems and other AI Agents

Imagine a system that identifies a care gap, books a follow-up appointment, and reminds the member—automatically, or an AI Agent that observes claims patterns, identifies outliers, re-queries missing info, escalates cases, and learns from resolutions. That’s an AI agent at work.

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