Aetna enlists AI to settle health insurance claims Posted on : Jul 25 - 2019

The health insurer developed an artificial intelligence application to resolve claims, freeing up staff to focus on higher-level tasks, says CTO Claus Jensen, who plans to automate other processes.

Aetna has created artificial intelligence (AI) software to settle claims, a solution that could provide a blueprint for broader automation of complex processes at the health insurance giant. The software rapidly parses complex healthcare provider contracts, whose blend of information about medical conditions and financial data often tax the patience of the trained humans who process them.

“It really comes down to providing a better experience” for end users, says Aetna CTO Claus Jensen, adding that the software will help the company be a better partner in the health-care ecosystem for providers and patients. “We have to do more than just pay the bills and answer questions on the phone.”

It’s a significant development at a time when all manner of companies are grappling with how to solve business problems with AI and machine learning (ML) technologies. Worldwide spending on AI systems is forecast to reach $35.8 billion in 2019, an increase of 44 percent over the amount spent in 2018, according to IDC, which placed healthcare at No. 4 in spending on AI, behind retail, banking and discrete manufacturing.

AI: A guidepost for automation

Aetna’s solution also highlights efforts companies are taking to reduce manual grunt-work performed by humans. Insurers, in particular, have emerged as leaders in adopting ML, AI and robotic process automation (RPA) to optimize business processes and improve employee productivity. Improving these areas, the companies believe, will in turn create a better experience for customers.

Aetna, like rivals Anthem and Cigna, has long experienced a difficult dilemma. Comments about financial data are included in Aetna contracts in free form, but industry software for resolving claims isn’t effective at parsing natural language or health terminology that differs from one healthcare provider to the next.

As a result, Aetna allocates 50 employees to read notes about payment, deductible, and extraneous fee explanations in each contract, calculate pricing and update the claim. And with Aetna handling 2.4 million contracts per year, the process takes weeks to months, and often results in incorrect payment for claims. That results in complaint calls from consumers.

"There is a lot of complexity hidden in the text, and it's not 100 percent standardized," Jensen says. "So the issue is, how do you understand in a computable fashion notes that are sitting in between the consumer, plan sponsor, and the health care provider, and how do you parse language in different contracts and match it up versus benefits?" View More