One of the 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 intensified the burden of claims processing, hence impacting negatively on the insurers’ ability to stay lean and innovate.

Adding to the complexity are the 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 even more.

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 throughout the insurance journey, leveraging AI delivers even further benefits. Take the streamlining of claims processing as an example.

Before using AI in claims processing at M-TIBA, CarePay's subsidiary in Kenya, 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 5 times, as well as reduced 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, that 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 onto innovative approaches.

Since implementing AI into the claim processing operations, claims assessment cycles are significantly reduced from weeks to seconds. More than 40 percent of the claims are automatically approved – and this fraction increases every day. These benefits are also felt by the providers, as we can facilitate faster payouts and reduce payment cycles. Therefore, lowering costs and enhancing the patient experience.

Technology has emerged as a key connector between industry players, and the developments in ML/AI will function as an accelerator. Especially, as consumers are looking for more personalized, digital experiences that empower them to manage their health needs. AI and tech can unlock this potential.

By leveraging data and AI, insurers can streamline the entire customer journey through easier admin and claim processing, engaging digital interactions, as well as personalized and affordable coverage based on consumers ’needs and behaviors. This shift from product-centric to customer-centric insurance creates a win-win: empowered customers and more affordable health insurance.

By Pieter Prickaerts, Managing Director at M-TIBA, CarePay's subsidiary in Kenya