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.