Wrapping up our 5-part series, this final blog discusses how complex yet effortless custom LLMs are redefining engagement strategies for health plans, paving the way for a more personalized member experience. (Click here to read part 4)
Imagine an AI system that not just understands healthcare terminology but knows your specific health plan inside out. That's the promise of custom Large Language Models for health plans. LLMs learn the relationships, or patterns, among words and phrases in enormous data sets. Generative AI (GenAI) tools draw on LLMs to create new content and summarize existing structured and unstructured data. The LLMs for popular gen AI tools, such as ChatGPT, and Gemini were trained on data found across the Internet. That’s great for generating first drafts and basic research but problematic when it comes to delivering accurate health information to members and patients. Not all medical information on the internet is accurate.
Health payers also have unique requirements that a generic LLM is unlikely to include. So, to get maximum benefit from AI/GenAI and machine learning tools, custom/customized LLMs are a must for health payers.
Health plans can fine-tune or tailor an existing LLM with their own data to create a more customized model through a process called fine-tuning.
Here's why they're essential:
Tailored knowledge: These LLMs are trained on your health plan's unique policies, procedures, and claims data, ensuring responses that are not just accurate but relevant to your specific context.
Enhanced compliance: By incorporating your regulatory requirements and guidelines, these AI assistants become powerful tools for maintaining compliance across all interactions.
Efficiency boost: Automating administrative tasks with an AI-powered Agentic workflow that truly understands your processes can significantly cut operational costs and improve efficiency by 50% to 80%.
Personalization at scale: Provide members with personalized responses, care plans, screening alerts based on clinical information, history and plan details, enhancing their financial and clinical journey without increasing staffing needs.
Data Security: Developing an in-house LLM keeps PHI and business sensitive data under your control, addressing critical privacy concerns and regulatory requirements.
Transforming Member and Provider Experiences
Custom LLMs open a world of possibilities for enhancing both member and provider experiences. Here are some exciting use cases:
For Members
24/7 Health Plan Wizard: Imagine a personal assistant that helps members understand their coverage in the context of plan benefits, medical policies and state regulations, streamline patient-provider matching, enhance patient engagement, and navigate complex health plan journey, anytime, anywhere.
For example - Under the Affordable Care Act (ACA), genetic counseling and BRCA (Breast Cancer gene) testing for women with specific personal and/or family cancer history should be covered with no co-payment for in-network providers. Medicaid coverage for genetic testing varies by state. Some states cover BRCA testing and other genetic tests, while others may have more limited coverage.
Which health plan provides the most optimal coverage with lower out-of-pocket costs?
Personalized Health Education: Deliver tailored health information and explanations based on each member's unique health conditions and plan coverage.
For example – based on the personal health history and risk factors, screening recommendations for Men over 50 may include Vision Screening, Depression Screening, Colorectal cancer screening, Prostate Cancer Screening, Blood Pressure Screening, Type2 Diabetes Screening, etc.
Smart Claims Assistance: Help members and providers understand their claims; EOBs/ERAs, explain denials, and guide them through appeals processes more effectively, ultimately improving member and provider satisfaction and reducing frustration with the claims process.
For Providers
Real-time Eligibility Checks: Provide instant, accurate information about a patient's coverage and benefits, streamlining the administrative process. E.g. coverage limits, prior authorization requirements, or nuanced benefit details for complex services.
Seamless Prior Authorizations: Guide providers through the often complex prior authorization process, reducing administrative burden and improving approval rates.
Clinical Decision Support: Offer evidence-based recommendations and treatment guidelines aligned with the health plan's policies, enhancing care quality.
Operational Efficiency: The Hidden Gem
While member and provider experiences are front and center, the operational efficiencies gained from custom LLMs are equally impressive:
Automated Claims Processing: Analyze and process claims more efficiently, reducing manual review to less than 5% and processing times to less than 3 days.
Fraud Detection: Leverage advanced pattern recognition to identify potentially fraudulent activities, protecting both the health plan and its members. Current capabilities rely mostly on structured data. Summarizing medical records and evaluating the case against clinical criteria and medical policies will accurately identify Fraud, Waste, and Abuse.
Dynamic Policy Management: Automatically update and communicate policy changes to stakeholders, ensuring everyone is always on the same page.
Predictive Analytics: Analyze historical data to predict future trends, aiding in resource allocation and risk management.
An AI-powered future in healthcare is imminent. For health plans looking to stay ahead of the curve, the time to invest in custom LLMs is now.
By leveraging the power of custom Large Language Models, health plans can significantly improve the ease of doing business. Members enjoy more personalized, efficient, and accurate services. Providers benefit from streamlined processes and better support. And health plans? They reap the rewards of enhanced member satisfaction, improved provider relationships, and significant operational cost reductions.
The healthcare industry stands on the brink of an AI revolution, and custom LLMs are leading the charge. For health plans looking to stay ahead of the curve, the time to invest in this technology is now. The future of healthcare is personalized, efficient, and AI-powered – and it's closer than you think.
If you missed any part of the series, be sure to check out the previous blogs for a comprehensive understanding!
For more information please contact Anup Panthaloor, EVP – Health Plans and Health Services or Deepan Vashi, EVP – Healthcare Payer Practice and Solutions Lead, Solutions Architecture, Firstsource. Visit Firstsource relAI to read about our suite of AI led platforms, solutions and offerings. Learn how we’re empowering businesses of all sizes to seamlessly integrate digital technology and AI into their operations to enable new levels of efficiency, innovation, and competitive advantage.