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.