By Rob Adhikari

Health plan executives today face unprecedented challenges: the need to reduce costs, improve operational efficiency, compete in an evolving marketplace, and deliver exceptional member experiences. Artificial intelligence (AI) offers a transformative opportunity to achieve these goals. Leveraging AI isn’t just a trend—it’s a strategic imperative for health plans seeking to remain competitive and member-focused in a rapidly changing landscape.

Driving Personalization and Proactive Care

AI enables health plans to deliver personalized support at scale. AI predicts individual needs by analyzing historical data and member interaction patterns and proactively delivers tailored solutions. For instance:

• If a member frequently inquires about medication coverage, AI can preemptively suggest cost-saving options, coverage details, or related wellness programs.

• Predictive analytics allow plans to identify high-risk members and initiate targeted outreach campaigns for chronic disease management or preventive care initiatives, improving member health outcomes and reducing costly interventions.
  
  

According to The New England Journal of Medicine, “Adverse drug events, decompensation, and diagnostic errors…have the greatest potential for improvement with AI,” demonstrating that integrating actionable AI insights can save lives while optimizing resource allocation.

Real-Time Insights for Superior Member Engagement

AI transforms contact centers into hubs of efficiency and empathy by analyzing real-time sentiment. AI tools assess a caller’s tone and emotional state, identifying frustration, confusion, or satisfaction. This allows agents to adjust their approach in the moment or escalate calls proactively. The result? Enhanced member satisfaction, reduced churn, and improved operational metrics.

Additionally, AI-powered systems provide agents with a 360-degree view of member data, integrating electronic health records, claims histories, and prior interactions. This equips agents to resolve complex inquiries efficiently and empathetically, fostering trust and loyalty.

Seamless Omnichannel Experiences

Members expect a consistent and seamless experience across all touchpoints—whether through phone, email, chat, or social media. AI enables:

• Omnichannel integration: Members can transition seamlessly between digital and human agents without repeating themselves, creating a cohesive and frictionless experience.

• Scalable personalization: AI ensures every interaction, regardless of channel, is informed by prior data, promoting member confidence and satisfaction.
  
  

According to the International Journal of Information Management, “AI-enabled CRM capabilities increase customer experience quality, enhance adaptability to market conditions, and foster service innovation,” positioning health plans to excel in competitive markets.

Human-AI Collaboration: The Best of Both Worlds

Despite AI’s advanced capabilities, some interactions require the empathy and nuance of human agents. For example, discussions around sensitive medical issues or complex care coordination benefit from the compassion that only a human can provide. AI augments these interactions by:

• Handling routine tasks and inquiries, freeing human agents to focus on high-value, empathetic interactions.

• Providing decision support, offering human agents insights and recommendations that enhance member outcomes.
  
  

This synergy between AI and human agents drives higher Net Promoter Scores (NPS), improved Star Ratings, and greater member retention. As noted in JMIR Cancer, “Human elements in health care will not be replaceable…but chatbots and AI systems can refine workflows, reduce costs, and improve outcomes.”

Why Health Plans Must Act Now

Health plans that embrace AI today position themselves as leaders in the industry, gaining a competitive edge through:

• Cost Efficiency: Reducing administrative burden and optimizing resource use.

• Member Satisfaction: Delivering personalized, proactive support that meets and exceeds expectations.

• Improved Health Outcomes: Using predictive analytics to intervene early and effectively.
  
  

AI is no longer an emerging technology; it’s the inflection point for health plans to redefine what’s possible. By investing in AI responsibly, health plan executives can achieve operational excellence, meet member expectations, and ultimately drive better health outcomes.

The future of health plans isn’t about keeping pace—it’s about setting the standard. AI is the tool that will take your organization there.

Rob Adhikari is Vice President of Sales at Sagility.

This article originally appeared in HealthCareBusiness News.