Healthcare Redefined Through AI Innovation
Health insurers are leveraging artificial intelligence to redefine their role in healthcare delivery. At HIMSS25‘s inaugural Emerge Innovation Experience in Las Vegas, industry leaders revealed how AI is empowering payers to take a more active role in care delivery while improving member experiences and operational efficiency.
How AI Is Reshaping Payer Operations
Payers have unique visibility into individual care needs and utilization patterns across the healthcare ecosystem. This comprehensive view positions them to implement AI solutions that enhance care delivery and member satisfaction.
“Culturally we encourage everyone to use AI,” said Aric Sharp, CEO of Value-Based Care at Clover Health. “The core of our focus is at the point of care.”
Clover Health has developed AI-powered technology to harness big data and run algorithms that facilitate early diagnoses and improve health outcomes. This approach represents a fundamental shift in how payers approach healthcare delivery.
Enhancing Member Experience Through Technology
Health plan members increasingly demand immediate access to information without lengthy phone calls to customer service centers.
“People don’t want to call us,” noted Heather Lavoie, Chief Information Officer and Executive Vice President of Enterprise Operations for Blue Cross Blue Shield New Jersey. “What they want is answers.”
To address this pain point, insurers are implementing AI assistants and chatbots that streamline member interactions and provide quick, accurate responses to inquiries about coverage and benefits.
Transforming Workforce Capabilities
The implementation of AI technologies is also helping payers address staffing challenges while enhancing employee effectiveness.
“It’s difficult to find people to work in a call center,” Lavoie explained. AI can summarize coverage information, allowing staff to work at a higher level. “We’re asking people to do the same job, but do it more effectively.”
SCAN Health Plan has partnered with Cresta, an AI-powered contact center platform that provides real-time guidance to agents during complex care conversations. “It’s listening in the background,” said Khin-Kyemon Aung, Senior Director of Healthcare Services, Medical Director, and Primary Care Physician for SCAN.
Advanced Data Integration for Personalized Care
Payers are moving beyond claims data to create more comprehensive member profiles.
“We’re bringing in sensor data, health risk assessments to create better profiles of members,” Lavoie shared. This enriched data enables more personalized care approaches and proactive interventions.
AI is also enabling sophisticated capabilities like voice interpretation for patients with Parkinson’s disease and helping case managers implement stratification so nurses can route cases appropriately by disease state.
To address this pain point, insurers are implementing AI assistants and chatbots that streamline member interactions and provide quick, accurate responses to inquiries about coverage and benefits. At HIMSS25’s inaugural Emerge Innovation Experience in Las Vegas, industry leaders revealed how AI is empowering payers to take a more active role in care delivery while improving member experiences and operational efficiency.
Barriers to Innovation and Future Direction
Despite technological advances, significant barriers to innovation remain. Sharp identified organizational culture and resistance to change as major obstacles, while Aung highlighted the challenge of aligning payer and provider incentives.
“We have to think about breaking the way the system works in its entirety,” Sharp asserted, suggesting that “revenue cycle could go by the wayside if we look at entirely different models.”
The panel discussion was moderated by Edward Marx, CEO of Marx Advisory and former global Chief Information Officer at Cleveland Clinic. Other participants included representatives from Humana, reflecting the industry-wide interest in how AI is transforming payer operations.
As AI continues to evolve, payers are positioned to play an increasingly important role in healthcare delivery, potentially reshaping the entire healthcare ecosystem for improved efficiency and outcomes.
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