Benefits Of Cognitive Computing

Enterprise automation platforms built on a cognitive computing foundation can help organisations reduce their rising costs

- Venkateshwaran Ananth

As healthcare insurance and healthcare payer organisations witness major changes in their environment, artificial intelligence with cognitive computing abilities holds significant promise for the industry. There are three important challenges for change management initiatives:

Change across multi-variant dimensions (Examples: consumer trends, payment innovations; and disruptor-induced removal of intermediaries from traditional payer models).

Uncertain nature of change (Example: Future of ACA and scope of CMS bundled payment).

Pace of change manifestation (Example: Last-minute CMS guidelines to operationalising ACA members)

Facing Complexities 

Health insurance organisations are facing significant complexities in their core business entities - product (and benefits), network and medical policy. While the passing of the ACA has had an impact, the complexity is also due to consumer-directed health plans or high deductible health plans gaining momentum as a means of involving customers in the cost equation. Payment reconciliation and member engagement aspects were further complicated by health saving accounts.

Initiatives to promote bundled payments (MLR mandates, ACO, PCMH and CMS drives) drove the payers to look for comprehensive payment innovations and led to significant carve-outs and special network arrangements to optimise the costs of specific demographics and high-cost procedures. As medical policies are used as guidelines by payer organisations for adjudging the necessity of specific procedures, any significant progress in medical science can put pressure on clinical staff in the UM area in evaluating cases vis-à-vis medical policies and new research.

Change Management and Implications