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attention-to-today/

LLM use cases building

to roadmap for Health
Insurance Payors
Andrew Bezaitis
Product and Program Executive | Driving 3 articles Follow
Innovation and Growth through people,…

July 13, 2023

Open Immersive Reader

Historically payor systems were built on manual processes

or best case rules engines. These engines didn’t scale or
adopt to ANY change in data and were not
refreshed. Analysis was one and done so often were quickly
abandoned and not used in operational workflows. AI
promises to change that operating model and allow
organization to operationalize their data for the key
problems they face. Below find a sample of using Chat GPT
to develop a list of use cases associated with Payor AI
Adoption and then begin refining for prioritization. This can
save plenty of “consulting” discovery and move an
organization quickly to the refining stage – which is where
the work is. Those steps include estimating the costs of
implementation and quantifying the value. The value to
Product Managers, Planners, Strategist and Architects

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comes quickly to light. Business Leaders should insist on

testing the planning process with tools like Chat GPT to
create and or evaluate the working framework.

In our example: Seven use cases were identified, and you

can see a quick drill into Provider Network
Optimization. This can be done in minutes and continue to
click down to organize the to-dos to surface value
creation. DATA cleaning and integration will be key steps
for EACH use case. Quality control and looking for
anomalies biases and or Hallucinations will also be a key
component. These risks are NO different than ANY other
analysis and or IT/Rules based solutions. Once the data
pipelines are in place, AI/Models simply expose responses
MUCH more quickly. The good news is they are organized
in a way that organizations can react and refine. LLMs do
not provide a silver bullet they change the work and offer a
far richer operational model. Just as Cloud changed how we
operate systems and software, AI/LLMs will change how
operational models work. Those who embrace this will be
winners over the next 5 years.

Use Case summary for Payors:

1. Claims Processing

2. Customer Support

3. Fraud Detection

4. Risk Assessment

5. Disease Management

6. Predictive Analytics

7. Provider Network Optimization

==================

Prompt: Provide Large Language model use cases for

Health Insurance Payors

Claims Processing: Health insurance payors deal with a

significant volume of claims from healthcare providers. A
language model can be used to automate and streamline
the claims processing workflow by extracting relevant
information from claim forms, verifying policy details, and

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assessing the validity of claims based on predefined rules

or historical data.

Customer Support: Language models can assist health

insurance payors in improving their customer support
services. By integrating the model into chatbots or virtual
assistants, payors can provide automated responses to
frequently asked questions, guide customers through policy
details, and assist in the resolution of common issues or
inquiries.

Fraud Detection: Health insurance fraud is a significant

concern for payors, leading to financial losses and
increased premiums. A language model can analyze large
amounts of structured and unstructured data to identify
patterns and anomalies indicative of fraudulent activities.
This can help payors detect and prevent fraudulent claims,
ultimately reducing costs.

Risk Assessment: Insurance payors rely on accurate risk

assessment to determine premiums and coverage. A
language model can assist in analyzing various data sources
such as medical records, demographics, and lifestyle factors
to evaluate the risk profile of individuals or groups. This
information can be used to refine underwriting processes
and pricing models.

Disease Management: Language models can be employed

to support disease management initiatives by providing
personalized recommendations and information to insured
individuals. By analyzing health data and medical literature,
the model can assist payors in delivering targeted
interventions, preventive measures, and health promotion
programs

Predictive Analytics: Utilizing historical data, a language

model can be trained to predict various outcomes such as
healthcare utilization, costs, or disease progression. These
predictive capabilities can assist payors in developing
proactive strategies for managing risk, optimizing resource
allocation, and improving operational efficiency.

Provider Network Optimization: Health insurance payors

often maintain networks of healthcare providers. By
leveraging a language model, payors can analyze provider

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performance metrics, patient feedback, and other relevant

data to optimize network composition. This can help ensure
quality care delivery, control costs, and enhance member
satisfaction.

Expand on Provider Network Optimization

1. Provider Performance Evaluation: A language model

can analyze a wide range of data sources, including claims
data, patient feedback, quality metrics, and outcomes data,
to evaluate the performance of individual healthcare
providers. By considering factors such as patient
satisfaction, cost efficiency, clinical outcomes, and
adherence to evidence-based practices, payors can identify
high-performing providers and prioritize their inclusion in
the network.

2. Network Adequacy Assessment: Language models can

help assess the adequacy of the provider network in terms
of geographic coverage and specialty availability. By
analyzing demographic data, population health needs, and
provider distribution, payors can identify gaps in the
network and target recruitment efforts to ensure that
members have access to the necessary healthcare services.

3. Cost and Quality Analysis: A language model can assist

in analyzing the cost and quality of care provided by
different providers within the network. By considering
factors such as reimbursement rates, procedure costs, and
quality metrics, payors can identify providers that offer
high-value care, balancing quality outcomes with cost-
effectiveness. This analysis can inform contract negotiations
and provider selection.

4. Member Preferences and Needs: Language models can

analyze member feedback, surveys, and other sources of
information to understand member preferences and needs.
By incorporating this data, payors can align their network
optimization efforts with the specific requirements and
preferences of their members, ensuring that the network
includes providers who meet those needs.

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5. Predictive Analytics: A language model can leverage

historical data to predict provider performance trends, such
as changes in patient volumes, readmission rates, or quality
metrics. By forecasting these trends, payors can proactively
adjust their network composition, adding or removing
providers based on predicted performance changes and
emerging healthcare trends.

6. Referral Patterns and Network Leakage: Language

models can analyze claims data to understand referral
patterns and network leakage. By identifying instances
where members seek care outside the network or are
referred to non-network providers, payors can take steps to
address the underlying reasons for network leakage, such
as limited specialty availability or long wait times.

7. Provider Engagement and Collaboration: Language

models can assist in fostering collaboration and
engagement with healthcare providers. By analyzing
communication patterns, sentiment analysis of provider
feedback, and other data, payors can identify opportunities
to improve communication, address provider concerns, and
strengthen relationships with key network providers.

By leveraging the capabilities of a language model, health

insurance

payors can make data-driven decisions regarding provider

network optimization.

This can lead to improved member satisfaction, better

health outcomes,

optimized costs, and increased operational

efficiency. However, it's

essential to combine the insights from the language

model with domain expertise

and consider regulatory and contractual obligations while

making network

optimization decisions.

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What is required to analyse referral patterns and network

leakage?

ChatGPT

Analyzing referral patterns and network leakage requires

access to relevant data sources and the application of
appropriate analytical techniques. Here are the key
components needed for this analysis:

1. Claims Data: Claims data is a valuable source of

information for analyzing referral patterns and network
leakage. It typically includes information such as the
services provided, the healthcare providers involved,
and the associated costs. Health insurance payors need
access to comprehensive and well-structured claims
data, which may come from their own internal systems
or be obtained from third-party sources.

2. Provider Network Data: To understand referral patterns

and network leakage, payors must have detailed
information about their provider network. This includes
data on contracted providers, their specialties,
locations, and the specific services they offer. This data
helps identify network gaps, assess network adequacy,
and track provider utilization.

3. Data Integration: Referral patterns and network

leakage analysis often require integrating claims data
with provider network data. This allows payors to
identify which providers are within the network and
which are outside of it. Integration can be achieved by
mapping provider identifiers in the claims data to the
provider network data, ensuring consistency across
datasets.

4. Data Cleaning and Preparation: Prior to analysis, data

cleaning and preparation are necessary to ensure data
quality and consistency. This involves removing
duplicates, handling missing values, standardizing
formats, and addressing any other data quality issues
that may impact the accuracy of the analysis.

5. Data Analysis Techniques: Various analytical techniques

can be employed to analyze referral patterns and

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network leakage. Some commonly used methods

include:

Network Analysis: Network analysis techniques can be

applied to visualize and explore referral relationships
between providers. This helps identify patterns,
clusters, and influential providers within the network.

Leakage Identification: By comparing claims data

against the provider network data, payors can identify
instances where members are seeking care outside the
network or being referred to non-network providers.

Quantitative Analysis: Statistical techniques can be

utilized to quantify the extent of network leakage, such
as calculating referral rates or identifying trends over
time. This helps measure the impact of leakage and
evaluate the effectiveness of network strategies.

1. Visualization and Reporting: Communicating the

findings of referral pattern and network leakage
analysis is crucial for decision-making. Data
visualization techniques, such as charts, graphs, and
maps, can be used to present the results in a clear and
accessible manner. Reporting on the analysis outcomes
helps stakeholders understand the extent of network
leakage and make informed decisions regarding
network optimization.

It's important to note that performing accurate and

meaningful analysis of referral patterns and network
leakage may require expertise in data analytics, healthcare
operations, and health insurance practices. Additionally,
compliance with data privacy regulations and protection
of sensitive information is paramount throughout the
analysis process.

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Andrew Bezaitis 3 Follow

Product and Program Executive | Driving Innovation and Growth through peop…
Published • 6mo articles

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#AI #LLM #Payor #businesstransformation

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