Tuesday, July 26, 2022

AI in Healthcare Series: Care Optimization & Other Use Cases

Introduction: AI in Healthcare Series 

This is the first in a new series of articles on AI in Healthcare, especially as it relates to what we at CognitiveScale are doing with clients like Elevance Health (formerly Anthem), CVS Health, United Healthcare, and Kaiser Permanente.  Initially, we will describe the key areas where are working with these clients, and get into the use cases and solutions across some key functional areas of their organizations: 

  1. Sales Acceleration
  2. Care Optimization
  3. Process Optimization
  4. Service Experience 
  5. Trust & Governance 

Care Optimization AI

These use cases correspond to functional areas of healthcare businesses, from acquiring new clients (members and patients), to then caring for them better (Care Optimization), to improving and optimizing back office operations and processes like claims processing, to serving customers better via the contact center.  CognitiveScale’s Cortex AI Platform also includes Trust and Governance capabilities that are specific to Healthcare.

Healthcare Sales Acceleration

From acquiring new members to supporting existing clients through the annual enrollment period, there are several Healthcare Sales Acceleration AI use cases where we have driven value for Healthcare clients, especially as it relates to delivering AI-powered Personalization solutions:

  • Personalized Cross-selling & Up-selling Insights: Based on an individual member profile, provide hyper-personalized insights about health plan options and additional benefit packages that may be of value.  These insights can be surfaced to agents, brokers, or directly to members.
  • Intelligent Lead Generation: Based on conversion and churn analysis, derive insights that can improve targeted marketing efforts and ad spend, and drive higher quantity and quality leads to health plan websites.
  • Personalized Shopping Experience & Offer Presentment: For website visitors and leads that have responded to more targeted ads (based on insights from churn and conversion analysis), personalize the shopping experience as quickly as possible.
  • Product Insights: Based on sales insights for qualified leads, applicants and members, offer product insights that help with product development (e.g. which products, benefits packages and price points work best by region).

Care Optimization

Professional services delivery in Healthcare generally means delivery of care by providers.  AI-powered Personalization solutions can generate hyper-personalized insights by member or patient and provide much more of a “guided path” experience, giving both patients and their caregivers insights and interventions that improve quality, outcomes, costs, and satisfaction.  

Use cases in Care Optimization include:
        • Chronic Conditions & High Cost Claims: Healthcare organizations - both payer and provider organizations - are leveraging AI extensively to improve the care of patients at risk of chronic conditions (or those already diagnosed), e.g. heart disease, chronic kidney disease, diabetes, etc.  Similarly, organizations are trying to prevent some high cost claims like low intensity emergency room (LIER) visits or other preventable expenses.  At CognitiveScale, our Cortex AI platform is helping with Care Optimization in a couple of unique ways:
          • Goal Optimized AI Campaigns not only help to improve the identification of at-risk patients or members with model outputs (risk scores, predictions, etc,), but our solutions enable organizations to then change the trajectory of an at-risk patient with Mission Plans and interventions that drive value (more of a personalized “guided path” experience).
          • From Model and Data Observability to Business Observability: in the case of Care Optimization, of course it is important to understand who your at-risk members and patients are, but Care Optimization means not only identifying at risk patients, but also delivering better care, lowering risks, driving better outcomes, etc.  The Cortex AI Platform enables this level of AI solution development, operationalization, monitoring and maintenance.
        • Care Interventions: Getting patients to get their annual flu shots, physicals, well-baby visits, and labs - or more irregular services like cancer screenings and colonoscopies - delivers clear benefits in the overall health and outcomes of patients.  Similarly, for patients at risk of heart disease, chronic kidney disease, and numerous other conditions, better compliance with care management and wellness programs can be challenging. Again, goal optimized AI campaigns based on hyper-personalized insights can improve the patient journey and drive a number of KPIs (outcomes, costs, etc.).
        • Star Rating Improvements: Cortex Goal Optimized Campaigns allow clients to set up specific cohorts to focus Care Optimization programs on, so when these cohorts relate to Medicare members, improving the percentage of members who get flu shots, annual physicals, cancer screenings and a number of other Star Rating measures can be extremely valuable.

Healthcare Process Optimization

Healthcare is rife with operational inefficiencies in areas like transaction processing.  Improving claims and prior authorization automation rates has been a long-term goal of Healthcare Information Technology (HCIT) initiatives.  More recently, AI use cases in Healthcare Process Optimization include:

            • Claims Processing Improvements: CognitiveScale’s Cortex AI platform has helped with the composition of solutions designed to improve claims processing via exceptions (or adjustments) automation, thereby improving auto-adjudication rates.
            • Prior Authorization Improvements: Similarly, other transactions like Prior Authorization can be automated with insights like member-specific plan attributes and benefits packages combined with AI skills and rules engines.  Additionally, we are working to help predict disruptions in Member Experience caused by prior authorization delays.
            • Payment Integrity (Fraud, Waste & Abuse): There are numerous AI use cases in Healthcare Payment Integrity from retroprospective and real-time fraud detection to inspection of claims for waste and abuse.  Cortex’s unique ability to help clients compose AI-powered solutions and orchestrate numerous models, algorithms, skills and agents is especially powerful in this Payment Integrity use case.  For example, understanding all of a given Provider’s claims and being able to inspect a claim with multiple models while also evaluating all of the similar claims attached to that provider can be particularly valuable.  Cortex allows for the application of multiple models, rules engines, and algorithms to this process.
            • Document Intake, Interpretation & Insights: In Healthcare it is still common to need data from sources that are printed like explanations of benefits (EOBs), health plan benefits stored in electronic documents, health plan applications, and medical record attachments.  There are a number of AI use cases for document intake, interpretation, and then personalized insights.
            • Call Center Transcript and Chat Transcript Quality Control: Clients are applying AI models and skills to interpret transcripts and understand tone and sentiment, caller ID, Member journey phase, and agent response quality and compliance.

Healthcare Service Experience

Trends in Digital Transformation have organizations looking to modernize their Contact Centers well beyond the more traditional capabilities of a Call Center, including the use of customer apps and portals as well as chatbots and personal messages.  Healthcare has many service inquiry types and most Healthcare organizations spend significant time and money to address these inquiries given the complexity of Healthcare data, the disparate systems that house it, and the challenges with bringing up an individual Members’ claims, benefits, and provider data in order to respond to an EOB or benefits inquiry, for example.  There is also a desire to improve user experience via apps and portals in order to more easily present members with customer service information based on personalized, predictive, and prescriptive insights.

Healthcare AI use cases in Customer Experience include:

            • Agent Assist Insights: Predicting when a member will call for specific reasons (claims, benefits) along with specific information designed to improve call handling time (AHT) and first call resolution (FCR) - integrated into CRMs for use by call center agents - can make a huge impact on costs and satisfaction.
            • Self Service Channels (e.g. Chatbots): Similar hyper-personalized member insights into claims and benefit inquiries can be surfaced in self service applications like chatbots.
            • Personalized Messages & Notifications: With personalized insights, clients are trying to drive more digital touches, thereby lowering costs due to call deflection.

"Hybrid" Use Cases: E.g. Care Optimization Insights via Service Experience Channels

We are seeing more clients expand the types of service inquiries that agents can handle - and especially the number of insights that agents can see about members once they have them engaged.  For example, when members call about an EOB or billing issue, agents may want to take the opportunity to discuss other member issues, like helping to get a Primary Care Physician (PCP) assigned in their area, or utilizing benefits like check-ups, free flu shots, and well-baby visits.  Consequently, we are seeing clients who want to centralize member and patient profiles complete with customer service, care optimization, and sales acceleration insights, for use across the enterprise.

AI Trust & Governance in Healthcare

Models and decisioning systems have to be trusted, used responsibly, and be compliant with internal and external policies.  Cortex has built in capabilities to help clients manage AI Trust & Governance to meet these needs.

In Healthcare, Trust & Governance use cases can include:

  • Care Inclusion & Advocacy: As Healthcare organizations use models and algorithms to determine who should get specialty care or be put in a care management program, there is the need to inspect models and data continuously for bias, explainability, robustness and more - and then there is the need to meet the needs of Compliance Officers, Risk Managers, Auditors and Regulators.
  • Coverage Inclusion & Advocacy: Similarly, Health Insurance companies are using AI to determine who gets covered or which services get covered, and again, these models and data need to be trusted and responsibly used.

Cortex AI Trust & Governance Capabilities

Care Opitmization through AI

Generates a composite trust score that measures data and model risks related to performance, data quality, robustness, explainability, fairness and compliance.
  • Robustness
    Provide the ability to detect and mitigate adversarial attacks while understanding how issues with data quality impact system perfomance
  • Bias & Fairness
    Ensure that data models are representative of the real world and AI models are free of algorithmic biases
  • Data Quality
    Ensure user visibility around data drifts, data poisoning, data validity and fit while certifying legal justifications to use and process data
  • Explainability
    Understand stakeholder concerns for decision iterpretability and provide business process, algorithmic and operational transparency
  • Compliance
    Ensure systems operate within boundaries of local, national and industry regulation and are built and controlled in a compliant and auditable manner

Conclusion: CognitiveScale Healthcare Expertise

CognitiveScale is working with a number of the largest Healthcare organizations in the country: Elevance Health (formerly Anthem), CVS Health, United Healthcare and Kaiser Permanente on the use cases and solutions mentioned here.   We are also actively engaged as an AI Platform Provider in working with our clients to build out their AI roadmaps.

Learn More

Contact us to explore how we can help your organization drive more value from your Healthcare AI initiatives. 

Email: sales@cognitivescale.com

Phone: 1-855-505-5001


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