Intelligent Automation in Health Insurance

Abstract

Automation has been initiated in some of the core functions of the health care industry, but they are not yet fully automated to drive the next level of automation called cognitive or intelligent automation. But, with the acceleration of the new age technologies like AI & ML, Blockchain, RPA, IoT, etc., the entire process of health care delivery, right from member enrolment to health care services, including paramedical and ancillary services of the health care ecosystem will become a fully automated in the next 10 years. This article highlights the applications of intelligent automation, the importance of clinical data coding, the development of integrated payment systems, auto-verification of hospital credentials, fraud detection, and control, etc. The intelligent automated system with appropriate data coding of diseases, procedures, and allied health care services, would enable insurers risk-based underwriting, design customized policies based on the individual risk profile, automated claim adjudication, and payment integrity. It also discusses the important features of HIPAA regulations of US Health Care and how these guidelines can be incorporated into the Indian health care data standards. More importantly, cognitive intelligence in health insurance would enable the policymakers to design better health care programs, support evidence-based research, better disease control, and cost management, which would ultimately ensure a better quality of health to the customers and the society at large.