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The Nairobian

How tech, AI can make health insurance more affordable

Opinion

By Pieter Prickaerts | May 22, 2024

One of the major concerns in the health insurance industry is the increase in claims frequency in recent years, consequently leading to additional increases in costs. The increase in claims has upped the burden of claims processing - impacting negatively on the insurers’ ability to stay lean and innovate.

Adding to the complexity are soaring healthcare costs, which have become increasingly challenging for insurers. Global medical costs have sharply increased in the recent past and are expected to rise further.

WTW Global Medical Trends 2024 survey shows that 58 per cent of insurers anticipate a higher medical cost trend over the next three years. Technology, including Artificial Intelligence, stands tall as a solution to making health insurance easier and more affordable.

While well-known technologies already made significant strides in improving efficiency and reducing costs in insurance, leveraging AI delivers better benefits. Take the streamlining of claims processing as an example

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Before using AI in claims processing at M-Tiba, claims passed the traditional claims automation engine. They were set aside for human, manual claims adjudication when conditions were unmet. It pushed the number of claims processed per day up by five times, as well as reducing the number of days between treatment and claim vetting by 96 per cent.

Now, such claims are handled by a Machine Learning (ML) model first, which automatically approves claims when all conditions are met. When the model is in doubt, the claim will be manually handled by a human claim assessor as the algorithms are never allowed to auto-reject a claim. Consequently, with ML, only a handful of claims are left with queries for human assessors before they are approved or rejected.

With these pressures lifted, teams can focus on evaluating more complex issues and looking at innovative approaches.

Since implementing AI into the claim processing operations, claims assessment cycles are reduced from weeks to seconds. More than 40 per cent of the claims are automatically approved.

These benefits are also felt by the providers, as we can facilitate faster payouts and reduce payment cycles, lowering costs and enhancing patient experience.

The writer is the MD at M-Tiba