\n<\/p>\n
Many of us have experienced the frustration of long waiting times to secure a patient slot in a clinic or hospital. Let\u2019s imagine Jane, a policyholder, facing a delay in diagnosis of her acute appendicitis. This delay results in limited treatment options, days of clinical examinations, extra hospital admissions, and additional medical procedures like blood tests, X-rays, and colonoscopies before surgery. Inadequate pain management and confusing discharge instructions further worsen her condition and take an emotional toll. Despite having comprehensive coverage, Jane receives a claims payout much lower than her medical bills, leaving her feeling frustrated and dissatisfied with her entire care journey.\u00a0<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n Jane\u2019s situation is not unique across the insurance industry. According to research conducted by Accenture <\/span><\/span><\/span><\/span><\/span>, <\/span><\/span><\/span><\/span><\/span>24% of consumers globally<\/span><\/span><\/span><\/span><\/span><\/a> were not satisfied with their health insurance claim experience. In this blog, we will delve into the health insurance claims experience in APAC, where China and Japan have an even higher dissatisfaction rate of 39% and 41% respectively. <\/span><\/span><\/span><\/span><\/span>Unfortunately, the <\/span><\/span><\/span><\/span><\/span>conservative claim cost management strategies used by many insurers, driven by legacy technology, limit the full utilization of available data, including historical context and patterns. This is starting to change but in baby steps. <\/span><\/span><\/span><\/span><\/span>45% of insurers have deployed claims intake using Gen\/AI<\/span><\/span><\/span><\/span><\/span><\/a> as a strategic bet but only 12% of insurers have deployed and scaled it. <\/span><\/span><\/span><\/span><\/span> This results in less informed and accurate decisions, often due to assessors manually piecing together scattered information, leading to inconsistent claim assessments. These challenges highlight the urgent need for a transformative approach to health insurance claims management. However, as highlighted in our <\/span><\/span><\/span><\/span><\/span>Getting past the transformation euphemism<\/span><\/span><\/span><\/span><\/span><\/a> report, the term \u2018transformation\u2019 has become a catch-all for insurers and not all change programs are created equal. There is a lot at stake. Outperforming insurers, those who get change right, stand to gain an average of 8.1 percentage points in improved premium revenues and 2.6 percentage points in reduced expense ratios. Therefore, a very deliberate and precise claims management strategy involving core platform modernization and the use of AI agents needs to be employed which we outline below.<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n Claim platform modernization is a strategic imperative<\/span><\/span><\/span><\/span><\/span><\/b>\u00a0<\/span><\/p>\n To attract and retain policyholders like Jane, it is paramount for health insurers to embed not only accuracy, speed and explainability but also crucially, empathy, in the claims management process. Platform modernization and collaboration with healthcare providers creates a connected healthcare ecosystem while integrating advanced AI with modern processes and strategic partnerships enhances decision-making and delivers consistent, timely, and accurate claims. The use of AI agents, which we\u2019ll expand on now, is crucial to ensure customers experience that all-important empathy.<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n Unlocking the potential of genAI in claims management: Super agents + Utility agents<\/span><\/span><\/span><\/span><\/span><\/b>\u00a0<\/span><\/p>\n In conjunction with platform modernization, to accelerate future-ready claims operations, insurers should leverage agentic AI for rapid deployment. <\/span><\/span><\/span><\/span><\/span>Agentic AI<\/span><\/span><\/span><\/span><\/span><\/a> are \u2018AI agents\u2019 that exhibit human-like behavior and interactions, operate independently using internal models, learning algorithms, and decision-making capabilities and, unlike traditional AI systems, require lower levels of human intervention. The genAI claims agents framework is built around two key roles within the workflow: Super Agents <\/span><\/span><\/span><\/span><\/span> and <\/span><\/span><\/span><\/span><\/span> Utility Agents.\u00a0<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n Super Agents<\/span><\/span><\/span><\/span><\/span><\/b> leverage genAI to enhance the claims experience through automated and digital intake, case summarization, verification, and adjudication with analytic-driven fraud, wastage and abuse detection embedded in the full journey.\u00a0<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n On the other hand, <\/span><\/span><\/span><\/span><\/span>Utility Agents<\/span><\/span><\/span><\/span><\/span><\/b> focus on extracting and validating data from documents, providing actionable insights to assessors while monitoring performance.\u00a0<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n With advancements in genAI and agentic AI, insurers can extract information from legacy tech stacks using AI models, enhancing claims decisions through summarization and synthesis, without needing a radical change of tech stack, operational and architectural transformation.<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n Connected customer healthcare for both treatment and prevention: Merging online and offline\u00a0<\/span><\/span><\/span><\/span><\/span><\/b>\u00a0<\/span><\/p>\n In Jane\u2019s case, as well as influencing her health outcome, early diagnosis could significantly reduce both her medical expenses and treatment time. The healthcare journey should begin the moment she feels sick, requiring an integrated approach to delivery. Close collaboration and information-sharing among patients, healthcare providers, insurers, and other stakeholders in the healthcare ecosystem are crucial. Insurers can play a pivotal role by driving seamless online-to-offline health and wellness services. With their resources, data, and strategic positioning, they can expand their preferred medical networks, providing patients with more options and enhancing claims cost visibility from the start of the care journey. Increased interactions through brokers and other distribution channels bring essential empathy and compassion to patients during times of illness.<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n In addition, insurers can play a pivotal role in emphasizing preventive care. Many insurers in Hong Kong have implemented or are considering incorporating health and wellness programs into their policies. For instance, some insurers have formed strategic partnerships with third-party healthcare providers to offer one-stop, cross-border medical services. Partnerships with various kinds of outpatient day surgery centers in Hong Kong exemplify this. They expedite patients\u2019 surgery and treatment experience and reduce unnecessary costs involved, such as room and ward services. Patients can access a wide range of offline medical appointments, including health screenings and diagnostics, via the insurer\u2019s mobile app, catering to different life stages such as pre-wedding and pregnancy. The goal is to promote proactive health management through integrated partnerships and reward customers for healthier lifestyles. Leveraging integrated health data, such as electronic health records, claims history, and health tracking wearables, enriched with population-wide data, empowers customers to monitor their health effectively. Collaboration with third-party platforms for health data <\/span><\/span><\/span><\/span><\/span> analytics ensures timely access to emerging health trends, enabling tailored services and personalized product offerings.<\/span><\/span><\/span><\/span><\/span>\u00a0<\/span><\/p>\n A shift towards an empathetic future<\/span><\/span><\/span><\/span><\/span><\/b>\u00a0<\/span><\/p>\n The integration of agentic AI in health insurance claims management is not just a technological advancement but a fundamental shift towards a more empathetic, efficient, and accurate claims process. By modernizing claim platforms and leveraging the capabilities of Super Agents and Utility Agents, insurers can significantly enhance the customer experience, reduce claim processing times, and minimize errors. This transformation is particularly crucial in the APAC region, where dissatisfaction rates are notably high, and the need for a connected healthcare ecosystem is more pressing than ever. Insurers who embrace these innovations stand to gain not only in terms of financial performance but also in building long-term trust and loyalty with their policyholders. Moreover, the emphasis on preventive care and the seamless merging of online and offline health services can lead to better health outcomes and reduced medical costs for patients like Jane. As the healthcare landscape continues to evolve, insurers that prioritize these strategic changes will be better positioned to meet the needs of their customers and thrive in a competitive market. <\/span><\/span><\/span><\/span><\/span>In our next blog<\/a>, we provide a roadmap as to how <\/span><\/span><\/span><\/span><\/span>insurers can truly reap the full benefits of reinvention. In the meantime, should you wish to discuss how agentic AI can work for your transformation journey, please contact us on linked in at <\/span><\/span><\/span><\/span><\/span>Marco Tsui<\/span><\/span><\/span><\/span><\/span><\/a> or <\/span><\/span><\/span><\/span><\/span>Sher Li-Tan<\/span><\/span><\/span><\/span><\/span><\/a> .<\/span><\/span><\/span><\/span><\/span>\u202f<\/span>\u00a0<\/span><\/p>\n<\/p><\/div>\n\n","protected":false},"excerpt":{"rendered":" Many of us have experienced the frustration of long waiting times to secure a patient slot in a clinic or hospital. Let\u2019s imagine Jane, a policyholder, facing a delay in diagnosis of her acute appendicitis. This delay results in limited treatment options, days of clinical examinations, extra hospital admissions, and additional medical procedures like blood […]<\/p>\n","protected":false},"author":1,"featured_media":7036222,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[94],"tags":[25423,41835,3767,11693,13083,597,11034,193359,59937,2253],"dealstore":[],"offerexpiration":[],"class_list":["post-7036221","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-insurance","tag-agentic","tag-agentic-ai","tag-blog","tag-claims","tag-generative-ai","tag-health","tag-insurance","tag-insurance-talent","tag-talent-management","tag-transforming"],"yoast_head":"\n