AI for better care: Timely information for quicker issue resolution
From timely and more personalized support to faster claims processing, AI is enabling health benefits issues to be resolved more quickly.
As health benefits continue to grow in complexity, individuals and organizations alike are seeking more efficient ways to resolve issues related to claims, coverage and administration. Artificial intelligence (AI) can help meet these challenges, with the potential to streamline health care experiences.
By responsibly harnessing AI's capabilities, UnitedHealthcare is helping address simple member questions, enabling customer service Advocates to provide more personalized support, simplifying the claims process and streamlining benefits administration and management for brokers, consultants and employers.
Helping address simple member questions
UnitedHealthcare is leveraging conversational AI to answer simple member questions and provide them with information related to their specific benefits coverage. And, if a member still needs to call in with a question, an AI-powered assistant works to determine the reason for the call so it can direct the member to the appropriate resource, whether self-service or a live Advocate.
AI is also being used to help predict customer intent before they speak, routing calls proactively to self-service or appropriate customer service advocates, which is reducing transfers and improving first-call resolution. Supporting over 245,000 monthly calls, Al now predicts intent for all Optum Rx callers, resolving 10% via self-service and routing the rest more efficiently.1 Moving forward, this capability is being expanded to other channels like chat, email and app interactions to provide faster, more personalized support.
Providing timely and personalized support
Once a member is routed to an Advocate or requires more hands-on assistance, AI provides those Advocates with more precise, tailored information in real time during the call. This includes providing relevant information, resources and actions that are contextual to the conversation and the member’s coverage with the aim of efficiently and compassionately resolving the member’s question or issue.
Not only can AI equip Advocates to better respond to calls from distressed members, it also identifies opportunities to prevent future issues from arising. About 71M calls to UnitedHealthcare Advocates were assisted by AI-enabled technology.2 And there were 56K fewer customer service calls from AI predicting common issues like prescriptions or payment problems.3
Simplifying the claims process
UnitedHealthcare is also using AI to help speed up the time it takes to submit and process a claim, reducing the potential for human error along the way to help prevent inadvertent denials or claims issues from occurring, which can delay care or payments. This includes enabling members to auto-fill claim forms by taking a picture of their documents. Additionally, AI helps with out-of-network claim submissions by populating medical field values, reducing the time required for submission from 12–15 minutes to just 3 minutes.4 This not only improves efficiency but has also nearly doubled the completion rates.
Another example is Optum Real, which leverages AI to enable information to be exchanged more easily between payers and providers. When it comes to claims, this transparency into payer criteria can give providers the insight they need to more accurately code and bill claims upfront, reducing the potential for inappropriate claim denials and unnecessary rework.
Delays in claims processing or claim denials can be a major source of frustration for employees and their families when they are seeking care, so it’s important that employers consider how a carrier is working to streamline the process and help ensure greater processing accuracy.
While AI can play a role in this, it’s critical to note that AI does not make decisions related to claims or prior authorizations. Trained experts retain final decision-making authority regarding coverage and medical care.
Streamlining benefits administration and management for brokers, consultants and employers
UnitedHealthcare is also exploring ways to leverage AI to help cut down on the time brokers, consultants and employers spend on administrative tasks related to enrolling members, administering or managing benefits, handling member issues and identifying potential gaps in care. This includes using AI to help evaluate and compare plans, automate information entry processes such as uploading enrollment forms versus manually typing the information, generate claims report summaries and provide answers to member questions. By automating routine tasks and providing timely insights, the platform aims to make benefits administration more efficient and effective for all stakeholders involved.
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