The healthcare payer industry is at an inflection point. Margin pressure has intensified alongside regulatory complexity and member expectations. The question leaders should be asking is: Are we using AI to transform healthcare or to automate the problems we already have?
When payer organizations evaluate technology investments, return tends to get reduced to cost savings. While AI should move that needle, true return on investment (ROI) in healthcare payer is more complex than that. The opportunity we see at ServiceNow is three-dimensional:
AI can help reduce administrative burden, streamline operations, and drive measurable cost efficiency across claims, utilization management, and member services.
In an industry where margins are thin and getting thinner, this is table stakes. Each of these operational areas has “low-hanging fruit” where automation and workflow modernization can help take out costs to deliver fast ROI.
The focus shouldn’t be just on efficiency, but also on the areas that truly matter for members, providers, and associates. This type or ROI may be difficult to track since it doesn’t always show up in a spreadsheet, but it’s important not to lose sight of the experience for hard-dollar savings.
This is the most overlooked opportunity but the most important. There’s a critical difference between fixing a broken process and assessing whether the process should exist in its current form. Identifying that can help address the potential return of the first two dimensions and offer longevity for the solution and savings based on fixing the root cause if the process is broken.
Some of the core operational workflows that govern payer organizations today—such as claims, provider data management, care management, disease management, and utilization management—are age-old processes that haven’t changed for decades.
They were built around manual workflows, siloed data, paper/inaccessible records, and fragmented legacy systems. Layers of technology have been added on top, but the fundamental structure hasn’t been altered.
AI and modern workflow technology enable leaders to evaluate why a process requires 20 steps and what it might look like if it were built differently using the data, tools, and automation that are available now.
If you want to transform the member and provider experiences, don’t start at the front end. Front-end AI applications such as conversational interfaces, member-facing chatbots, and digital engagement tools are visible and easy to demonstrate, but they’re not where sustainable ROI lives.
The highest-impact work happens in the middle and back offices. The workflows nobody sees are the ones that determine whether:
- A pending claim gets resolved in two days or two weeks
- A provider gets an authorization decision before a patient's condition worsens
- Associates spend time on complex, judgment-intensive work or chasing records or other clerical work
For too long, the payer industry has operated reactively. A member receives care, and the provider files an authorization request or a claim based on care delivered. A problem surfaces, and the system responds. But connecting the problem to payer services to help the member often takes six to eight weeks.
By then, the member will likely have lost trust. According to Adoreboard's Trust Index, 95% of U.S. health insurers have negative trust scores, with 19 of 20 insurers scoring between -42 and -54 (on a scale of -100 to 100).
Payer organizations should have people’s backs. One example of where payers can build trust is in patient data. Organizational silos prevent primary care physicians (PCPs) from accessing patient details on hospital stays, MRIs, and other healthcare procedures so that the PCPs can swiftly follow up.
AI in healthcare can help payers consolidate patient medical records across every touch point and advocate for members. That way, a member’s care team (PCP, specialists, etc.) knows about their urgent care visit last month, their hospital stay six months ago, or labwork—without the member having to remember to mention it or carry around papers and CDs.
Think about the impact of that on areas such as care management/disease management and utilization management/prior authorization. It can also positively affect key metrics for a payer, such as medical loss ratio, simply by surfacing needed data to the appropriate folks at the right time. That’s the power of modern, AI-enabled workflows.
Back-end transformation is hard and requires deep thinking about intelligent workflow architecture, data infrastructure, and organizational change. But it can deliver ROI across all three dimensions.
The healthcare payers that lead in the next decade won’t be the ones that move fastest to put AI in front of their members. They’ll be those that rethink the operational foundation and transform age-old processes with intelligent workflows and automation to help drive impact at scale.
Find out more about how ServiceNow can help you put AI to work for health insurance.
