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Sagility Achieves Major Sustainability Milestone with SBTi Validation of GHG Emissions Targets

Bengaluru, India | June 2nd, 2025: Sagility India Limited (NSE: SAGILITY, BSE: 544282), a leading global provider of technology-led business solutions and services to clients in the U.S. healthcare industry, today announced that its near-term greenhouse gas (GHG) emission reduction targets have been officially validated by the Science Based Targets initiative (SBTi).

The Science Based Targets initiative (SBTi) is a global climate action organization that empowers businesses and financial institutions to contribute meaningfully to the fight against climate change. Through the development of robust standards, tools, and guidance, the SBTi enables companies to align their greenhouse gas (GHG) reduction goals with climate science and the overarching objective of limiting global warming to avoid catastrophic impacts. 

SBTi Services has validated that the science based GHG emission reduction target(s) submitted by Sagility conform with the SBTi Standards and Guidance (Criteria version 5.2). SBTi Services has also classified the company’s Scope 1 and 2 target ambition in conformance with the SBTi Standards and Guidance.

Our Near-Term SBTi Targets: Sagility commits to reduce absolute scope 1 and 2 GHG emissions 54.6% by FY2034 from a FY2024 base year. Sagility also commits to reduce absolute scope 3 GHG emissions from purchased goods and services, capital goods, fuel- and energy-related activities, and employee commuting 32.5% within the same timeframe.

This validation reaffirms Sagility’s commitment to the 1.5°C pathway, with clear, science-based goals.

This milestone is an important step in Sagility’s broader sustainability commitment and long-term strategy to contribute meaningfully to climate action. 

Commenting on this milestone, Ramesh Gopalan, Managing Director and Group CEO, Sagility said:
“The validation of our near-term targets from SBTi is an important milestone for us. In partnership with our clients, talent, and the communities we operate in, we are committed to building a climate-conscious organization.” 

About Sagility India Limited

Sagility is a technology-led, healthcare-focused solutions and services provider that supports U.S.-based payers, providers, and their partners in delivering best-in-class operations, enhancing member and provider experiences, and improving the quality of care, all while ensuring cost-effective financial and clinical outcomes. With over two decades of experience, Sagility’s dedicated experts address complex healthcare challenges through deep domain expertise and innovative thinking. The company serves five of the top ten health insurance companies in the U.S., utilizing its advanced technology, processes, and solutions to ensure efficient operations and minimize additional administrative costs. The Company delivers these services through its skilled talent pool across five global service delivery centres located in India, the Philippines, the U.S., Jamaica, and Colombia.

Health Plan Tech Transformation To Improve the Member Experience, Lower Costs

By Michael LeVangie

Getting ahead of digital transformation is difficult for healthcare organizations. There’s AI, GenAI, Agentic AI, and new uses for existing AI technologies that help staff get work done more efficiently.

With these rapid changes, an organization can’t keep up with the changes on its own. That’s where a consultant comes in.

Consultants benefit healthcare organizations in many ways, not the least of which is staying abreast of technology changes, new ways to use technology, associated regulatory updates, and suggestions on program implementation.

As a board member of a mental health organization, I’m always thinking of ways to improve the experience related to supporting positive mental health outreach and treating mental health conditions. I see a significant opportunity for health plans to use technology or digital transformation as a way to lower costs and improve the mental health of members. 

Behavioral health and technology

Behavioral and mental health challenges, exacerbated by the pandemic, remain a constant and growing issue for people of all ages. One in five adults—59.3 million people in 2022—live with mental health challenges today in the US, according to the National Institute of Mental Health. While the size of this number is tragic, it’s also an unprecedented opportunity for health plans to reach out and help their members. 

Thankfully, the stigma around mental health has decreased significantly over the past 20 years. People are more likely to openly discuss mental health issues than they were.

This is great news for healthcare organizations, which can get ahead of member mental challenges by expanding or creating innovative programs.

Utilizing technology—predictive analytics and Agentic AI—is a great place to start. I’ve mentioned this before and it bears repeating: health plans have an astounding amount of data just waiting to be analyzed. (Statista suggested that the total amount of healthcare data generated worldwide in 2020 would be 2.3 exabytes. The World Economic Forum, says 97% of data produced just by hospitals every year is never unused.)

A consultant with healthcare expertise can help payers identify and evaluate the data by applying predictive models to the information. This can guide health plans in the right direction when they want to grow or build a new mental health program for members. 

This retrospective exploration of data is an exceptionally important way to identify members. To enable a prospective approach to this data, health plans can identify a member’s need for mental health services through the use of Agentic AI. 

When Agentic AI interacts with members online, there’s an opportunity to triage the member in real time. When the caller describes the information they need, Agentic AI can understand the member’s tone of voice and mood. Combine Agentic AI’s ability to sense emotions with the potential for accessing the caller’s claims on the fly, and the potential to triage the member as they communicate becomes a reality. “Socially savvy agents represent the intersection of AI and emotional intelligence. These systems understand and interpret human emotions, beliefs, and intentions, enabling richer interactions,” according to an article in Forbes.

The health plan could create a virtual intake channel and classify members based on the Agentic AI’s training, including scheduling a doctor visit or making a warm transfer to a healthcare provider. 

The interplay between technology and behavioral health can help address the nurse shortage, while increasing the number of members receiving mental health care. By identifying and acting on the mental health issue early, health plans can drive down healthcare costs and improve member experiences.

Uniting people and technology

Consulting is the convener of minds. It serves to bring together siloed programs and departments into a cohesive whole to benefit the health plan and its members.

In the example above, healthcare consultants: 

  • Create workflows to get members into the system quickly
  • Interview payers and providers about the mental health markers that place members into high-, medium-, or low-risk groups
  • Build predictive analytics models to identify who needs assistance
  • Work to ensure the integration of internal and external technologies
  • Guide internal and external teams to ensure successful program implementation and iteration
  • Support change management

As technology continues to change and improve, the opportunity for healthcare organizations to maximize the potential of these advances will grow. With the assistance of a knowledgeable healthcare-focused consultant, the idea of technology transformation becomes a reality.

Michael LeVangie is Senior Vice President of Consulting at Sagility.

This article originally appeared in HIT Consultant.

Interview: Jill Warren, RN and SVP of Clinical Operations at Sagility, Speaks about Top Nursing Issues

National Nurses Month is underway, offering an important opportunity to reflect on the challenges and opportunities facing today’s nursing workforce. In this Q&A, Jill Warren, senior vice president of clinical operations and global clinical governance at Sagility, shares insights on the top issues impacting nurses in 2025 – from burnout and staffing shortages to the role of technology – and explores what healthcare organizations can do to support and retain this essential part of the care team.

With National Nurses Month approaching, what are the top three issues impacting nurses today?

Nurses face many issues today. When I think of the top three, here’s what I read, see, hear, and experience in the market.
  1. Burnout persists. Unfortunately, the impact of COVID-19 is still with us. For those nurses who were really engaged in clinical practice during the pandemic, the aftereffects of COVID-19 continue to drive an even higher amount of burnout, causing nurses to leave the profession.
  2. Working conditions. As leaders, we need to monitor the impact of work/life balance to prevent burnout. Many nurses are called in to work even on their days off because of the nursing shortage, which in turn drives even more burnout. Nurses are moving out of the field entirely or retiring early, which results in even more shortages.
  3. Tech innovations. Digital advancements are also impacting nurses today. As technology becomes more entangled in healthcare, more mature nurses will have to adjust how they practice nursing and deal with all the modernizations, including AI, telehealth, and wearable devices.

The National Council of State Boards of Nursing (NCSBN) released data revealing that more than 138,000 nurses have left the workforce since 2022, and by 2029, almost 40% of nurses – 1.8 million – intend to leave the workforce. This shift in personnel threatens the national healthcare systems at large, especially as Baby Boomers retire, if solutions are not enacted to address this.

These changes over the last several years will continue to affect nursing in the future.

Is there a nursing shortage in 2025? What’s causing it?

The data show that the shortage will continue for quite some time. When you consider the 1.8 million anticipated to leave the field, it’s a significant problem.

Given the current shortage, how are we going to replace nurses in the future? The downward spiral really accentuates the need for nursing education. But even in nursing education, we have a shortage of highly qualified instructors.

As these people leave, the question is: How will we backfill and train the numbers necessary to overcome the shortage?

The shortage becomes more acute as we all live longer, suffer from chronic conditions, and need more care at home or in facilities.

It’s a Catch-22. The demand for nurses continues to grow, but the supply struggles to keep up.

What can be done to ease the shortage in 2025? And in the future?

We have to support nursing education and invest in nursing faculty so that we can enroll the number of nurses needed in the future. Focusing on the higher education system is the foundation for helping us overcome the nursing shortage.

How can recruitment and retention strategies improve nursing as a career?

It really comes down to training, education, wages, and benefits.

Lifelong learning is really, really important to nurses. Sagility’s staff wants continued training and to grow professionally. Motivation is a very important component relative to recruitment and retention.

Investing in programs that support higher education is imperative; when a nurse has an associate nursing degree, they can take advantage of opportunities to support them in gaining their bachelor’s, master’s, and even doctoral degrees.

Employers offering training and education to address the desire for lifelong learning will have an advantage in terms of retention.

Nursing is an extremely competitive market, which has driven up salaries. Wages increased during COVID and have continued to rise, although growth has slowed recently. Companies that want to offer competitive wages must understand that pay is very regional. The Northeast and Northwest have very high salary structures, compared to certain areas of the Midwest and the South.

A benefit structure is also extremely important. Once again, we see this in our own organization, and we’ve taken action to address retention and recruitment issues within Sagility as they relate to the benefit structure, including paid time off.

Schedule flexibility has become an important factor affecting the recruitment and retention of nurses. Does the employer support them when they want to attend their children’s activities? Are they able to volunteer within the community that the employer supports?

In addition, employee mental health and behavioral health support is another key area. This support helps address burnout and the response to stress before it takes hold, while also helping to improve work/life balance.

What’s the future of nursing? How will it be affected by AI or other technologies?

AI and other technologies are affecting nursing now and will continue to into the future. Nurses are faced with using technology every day, and this occurrence will continue to expand within healthcare. And that’s a good thing.

However, we do need more training heavily focused on AI and machine learning, for example, because both will change how nurses spend time delivering care.

For many, using these technologies can cause anxiety. But I think it’s important as nurses that we focus on new ways of doing things and embrace these changes.

We need to be less concerned with the thought that AI is going to replace our work and more focused on how AI can support our work in the future.

Jill Warren is Senior Vice President of Clinical Operations and Global Clinical Governance at Sagility.

This article originally appeared in Hospital & Healthcare Management.

Silos: Great for Farms, Not for Healthcare

By Mitesh Kumar, Senior Vice President – Claims Practice

Silos make sense on farms. In healthcare, they can lead to disaster.

Nevertheless, those of us who use healthcare—providers and patients, payers and members—or work in adjacent businesses are forced to deal with silos every day. This is especially true when it comes to the claims process. Claims information is often found across several data silos.

Each time we visit a healthcare provider, a claim is created. From there, its route is circuitous at best. At worst, a convoluted journey that passes through a series of data silos, finally getting resolved after being touched by multiple systems, people, and departments. Most dashboards today simply offer user metrics and highlight existing problems like pend rates and rework.

Claims silos become an enormous problem quickly considering that payers process 5 billion and deny 850 million claims every year.

Thankfully, there’s a better way.

Mapping Complex Journeys

Progressive BPO solutions use process mining to map out complex claim journeys—along with insights from a team of experts—to help healthcare businesses understand where and why problems occur. It provides a single view of how a claim flows through the organization, and where, why, and what causes it to get stuck in the process.

For example, if the provider’s appeal rate is high (delayed or incorrect resolution can impact Star Ratings), a tech-enabled solution can use process mining to visualize the end-to-end journey of an appealed claim. Process mining helps you understand where and why problems occur through a single, real-time view of how a claim flows through the organization. By mapping claims data upstream and downstream, a payer can gain insights working with an experienced team to understand where, how, and why the claim was denied and work to improve the process to lower the number of unnecessary appeals.

A bonus of a tech-enabled solution is its ability to build a timeline and sequence of each activity, which can help payers identify intervention opportunities to prevent similar appeals in the future.

This new examination of claims supports process flows, rather than creating an environment where the claim is destined to bounce from silo to silo. 

Break Down Silos with Process Mining

Process mining breaks down siloes by using system data to examine and locate areas for improvement. By revealing how processes truly function—where they excel and where they lag—process mining helps organizations identify inefficiencies and streamline workflows. The method identifies hidden patterns, which provides a better understanding of how processes are executed. This helps organizations understand where improvements can be made.

As operational silos are removed, payers will experience several immediate advantages. Easily accessible data and processes serve to improve business and operational processes, as well as member and provider relationships.

When breaking down operational silos these benefits are created:

  1. Reduce Provider Abrasion: Streamline processes to identify critical touchpoints, improving communication and transparency with providers.
  2. Fast Turnaround Times: Establish process models that pinpoint optimization opportunities, accelerating the claims processing cycle, which reduces provider and member abrasion. 
  3. Improve Operational Efficiency: Create significant reductions in administrative costs, benefiting all stakeholders in the healthcare environment.  
  4. Decrease Late Claim Payment Interest: Restructure workflows to prevent avoidable delays and identify bottlenecks, which result in lower interest payout.

Using this extremely efficient solution, coupled with input from dedicated experts, streamlines the claims process, eliminates gaps and redundancies, and supports transparent communication and seamless information exchange with members. 

The best part? This approach removes the silos by strategically addressing everyday and exceptional issues that plague the claims process. By doing so, payers positively impact all stakeholders, and the result is immense: It improves payer’s operations, reduces provider abrasion and enhances the member experience. 

Fostering these improvements is the ultimate goal for each of us who work in healthcare. 

Mitesh Kumar is Senior Vice President of Practice at Sagility.

This article originally appeared in Healthcare Business Today.

Sagility Named a Major Contender in Payment Integrity by Everest Group in 2025 PEAK Matrix®

Tech-enabled healthcare BPM firm earns recognition for vision and strategy, technology innovation, and delivery impact in payment integrity 

ATLANTA – May 6, 2025 – Sagility, a leading tech-enabled business operations solutions and services provider in the healthcare sector, today announced that it has been named a Major Contender in the Everest Group Payment Integrity Solutions PEAK Matrix® Assessment 2025.

The PEAK Matrix® is a proprietary framework used by Everest Group to assess service providers based on their overall vision, capability, and market impact. The 2025 Payment Integrity Solutions PEAK Matrix® evaluated 24 global service providers focused on helping payers reduce waste, fraud, and abuse while improving cost containment and operational efficiency.

“This recognition by Everest Group reflects the significant strides Sagility has made in advancing payment integrity solutions through cutting-edge technology, intelligent automation, and clinical insight,” said Sohail Djariri, Chief Growth Officer of Sagility. “As healthcare payers face rising pressure to improve accuracy and reduce costs, our team remains focused on delivering measurable value through innovation, scalability, and strategic alignment with our clients’ evolving needs.”

Sagility was recognized for its vision and strategy, technology and innovation, and value delivered across the payment integrity landscape. The company offers a holistic set of solutions spanning both pre-pay and post-pay functions, enabling healthcare payers to implement integrated, end-to-end payment integrity strategies. Sagility’s approach combines deep domain expertise with automation and AI-driven insights to streamline audits, reduce claims leakage, and enhance cost containment. Its proprietary platforms and use of generative AI tools further strengthen its ability to support payers of all sizes with scalable, adaptable solutions.

“With claims leakage continuing to erode margins and healthcare payers shifting toward integrated payment integrity strategies that span both pre-pay and post-pay functions, success in this landscape requires a combination of domain expertise, automation, and AI-driven insights to streamline audits and reduce leakage,” says Ankur Verma, Vice President at Everest Group. Sagility brings a holistic set of offerings across all segments, backed by proprietary platforms and generative AI tools, enabling it to effectively meet diverse payer needs. These capabilities have contributed to its positioning as a Major Contender in Everest Group’s Payment Integrity Solutions PEAK Matrix® Assessment 2025.”

For more details on Sagility’s recognition in Everest Group’s Payment Integrity Solutions PEAK Matrix® Assessment, visit: https://www.everestgrp.com

About Sagility

Sagility is a tech-enabled, U.S. healthcare-focused business operations solutions and services company that supports payers, providers, and their partners in delivering best-in-class operations, enhancing member and provider experiences, and improving the quality of care, all while ensuring cost-effective financial and clinical outcomes. With over two decades of experience, Sagility’s dedicated experts address complex healthcare challenges through deep domain expertise and technology innovations. The company serves five of the top ten payers in the U.S., utilizing its advanced technology, processes, and solutions to ensure efficient operations and minimize additional administrative costs. The company delivers these services through its skilled talent pool of over 38,000 professionals across five global service delivery centres located in the US, India, the Philippines, Jamaica, and Colombia.

Disclaimer 

Licensed extracts taken from Everest Group’s PEAK Matrix® Reports, may be used by licensed third parties for use in their own marketing and promotional activities and collateral. Selected extracts from Everest Group’s PEAK Matrix® reports do not necessarily provide the full context of our research and analysis.  All research and analysis conducted by Everest Group’s analysts and included in Everest Group’s PEAK Matrix® reports is independent and no organization has paid a fee to be featured or to influence their ranking.  To access the complete research and to learn more about our methodology, please visit Everest Group PEAK Matrix® Reports. 

About Everest Group

Everest Group is a leading research firm helping business leaders make confident decisions. We guide clients through today’s market challenges and strengthen their strategies by applying contextualized problem-solving to their unique situations. This drives maximized operational and financial performance and transformative experiences. Our deep expertise and tenacious research focused on technology, business processes, and engineering through the lenses of talent, sustainability, and sourcing delivers precise and action-oriented guidance. Find further details and in-depth content at www.everestgrp.com.

Read the press release here 

How Agentic AI Helps Improve Health Outcomes, Reimbursement, Star Ratings

By Zaffar Khan

The idea of helping health plans increase member enrollment in health risk adjustment programs that improve health outcomes, care coordination, and quality of life is nothing new.

But the way it can be accomplished today is. 

GenAI voice agents, or Agentic AI, are poised to relieve call center agents of repetitive tasks easily handled by the technology. GenAI can help improve functions and processes critical to health plan success.

These are a few key areas where GenAI voice agents can contribute to health plan success:
  
  • Improved reimbursement by CMS: CMS uses risk adjustment models to determine how much to pay health plans for each member. 
  • Better manage member health: With a better understanding of their members’ health risks, health plans can develop programs and interventions to improve their health and lower costs. 
  • Improve Star Ratings: Star Ratings are a quality rating system used by CMS to evaluate Medicare Advantage plans. Plans with higher Star Ratings can earn bonus payments and attract more members. 
  • Better negotiate with providers: Health plans can use their risk adjustment data to negotiate better rates with providers.

There will be occasions, undoubtedly, when the member doesn’t have the time to talk or would rather not talk to GenAI voice agents, though as discussed earlier, many of us can’t tell the difference between the technology and a human speaker. Nevertheless, if this occurs, the solution will generate a text and send it to the member along with a secured portal link with all the needed information security and privacy guard rails to fill out the HRA online. For those who choose not to engage with a GenAI voice and are not interested in using a portal link, there is an option to speak directly with a live agent.

Operational, Business Benefits for Payer-to-Payer Interactions 

A GenAI voice agent supports payer-to-member communications; it can do the same for payer-to-payer communication in several important ways. Confirming member coverage is a time-consuming, arduous task. Every health plan, however, weathers the process. With the assistance of a GenAI voice agent, however, health plans can shift much of this work to this emerging, powerful technology. 

The voice GenAI agent can make outbound calls to other payer organizations to collect the member’s eligibility details for primacy coverage determination, which enables the coordination of benefits between payers. 

In addition, a GenAI voice agent supports efficient claims processing through the automation of routine tasks like claims verification, eligibility checks, and prior authorization requests. This reduces processing time and mitigates costly errors. 

The technology can help payers improve:

  • accounts receivable and accounts payable
  • cash flow
  • incorrect denial of claims
  • rework
  • appeals 
  • potential late claims, interest, and penalties
  • provider abrasion
  • member experience

This class of automation can lead to significant cost savings by reducing labor expenses and improving operational efficiency. 

Enhancing Relationships: Payers, Providers, Members

The GenAI voice agent can help build and maintain relationships among payers, providers, and members. By absorbing several health plan challenges, GenAI voice agents free up staff for more strategic, fulfilling activities within the business. 

A GenAI voice agent approach ensures member information is captured and acted upon by the health plan and the member’s care coordinators, caregivers, and providers. Across the board, the technology promises to help advance healthcare in 2025 and beyond as an easily scalable solution to handle ever-increasing call volumes and growing member populations.

Zaffar Khan is Associate Vice President of Business Transformation & Generative AI Solutions at Sagility.

This article originally appeared in Healthcare Contact Center Times.

AI Empowers Health Plans to Achieve Operational Excellence, Member Satisfaction

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.

Why GenAI Voice Conversations are the Next Frontier in Healthcare

By Zaffar Khan

As use cases for and the acceptance of GenAI continue to grow, health plans have a unique opportunity to not only push the envelope but rip it wide open. 

The next step in the evolution of conversational AI is GenAI voice agents. These agents engage in fluid and natural conversations and better understand nuances in human language. This leads to more accurate and contextually appropriate responses. Importantly, they can generate more human-like speech with variations in tone, intonation, and emphasis, making interactions more engaging. 

Building a GenAI Voice Agent

Launching a GenAI voice agent, or Agentic AI, offers health plans a multitude of possibilities to design and implement the technology to showcase the organization’s dedication to customer service, continuous improvement, and much more.

These are a few ideas that demonstrate the different ways to train the technology and the resulting organizational advancements:

Custom healthcare data: Voice AI agents powered by large language models (LLM) and small language models (SLM) provide the ability to fine-tune general-purpose models. In healthcare, custom vocabulary and medical terminologies can improve model performance and accuracy. The model can learn from ICD-10, SNOMED CT, and RX Norm, to name a few.

Empathetic responses: LLM powered AI agents can generate responses that acknowledge and validate the member’s feelings. This includes phrases like “I understand this must be difficult for you,” or “It sounds like you’re going through a lot right now.”  

Tone and voice modulation: The AI’s voice changes to convey warmth and concern, including adjusting the pace of speech, intonation, and overall tone. This creates a more comforting and human-like interaction.  

Privacy and data security: Open source LLMs and SLMs provide the flexibility to be hosted on-premise or in the cloud with required information security while handling sensitive patient data with strict adherence to privacy regulations like HIPAA. 

Each process applied to GenAI voice agents—to varying degrees—has led to something of a revolution in the healthcare contact center field “Generative AI has advanced significantly in recent years. It began with rudimentary algorithms that could only generate limited and predictable patterns and has progressed to more complicated tasks such as replicating human-like conversational abilities and making realistic visuals and sounds,” according to the International Research Journal on Advanced Engineering Hub. 

There is a movement underway thanks to this evolution to supply chatbots with “human” voices. It turns out, most people can’t tell the difference. 

A survey by Podcastle found that people “don’t know the difference between AI and humans – 2 in 3 incorrectly guessed that a human voice was AI.” In addition, 53% of those surveyed said they have a positive or neutral view of “AI voice technology.”

While people may be willing to converse with GenAI to get details on repairing their car, for example, having a similar interaction as a health plan member will be quite different. But the outcome: imparting timely, accurate information should be the same.

Improving Member Engagement

A GenAI voice agent can support member engagement, leading to improved health outcomes. Its job of communicating with members can help health plans accomplish several goals related to improving operations through personalized health coaching and guidance:
  • Tailored interventions a real-time support: AI Voice agents can deliver personalized health coaching based on individual member needs, risk factors, and preferences. Members can receive immediate support and guidance, such as reminders to take medications, tips for healthy lifestyle changes, or advice on managing chronic conditions
  • Health risk assessment (HRA): Engage members with care coordination and enroll in CMS-driven risk assessment programs  
  • Survey and feedback collection on QAA (Quality of care, Attitude of provider, and Access to care) issues: Automated Voice AI surveys can gather valuable member feedback on service quality, physician interactions, and overall satisfaction with health plans. 
  • Health check-ins and educational outreach: AI agents can conduct routine health check-ins, inquiring about symptoms, medication adherence, overall well-being, and personalized health education messages, explaining complex medical information in easy-to-understand terms.

Simply put, the GenAI agent calls the member to ask if they have time to complete an HRA and collect the information through a series of questions determined by the health plan. (Members called are based on CMS-guided HRA questions and frameworks—diagnosis of a chronic condition or frequent emergency department use, for example—as stipulated by the health plan.) also ensuring personalized and empathetic interactions. 

Voice-enabled GenAI agents can help health plans maintain relationships with members while gathering essential information that can improve care coordination, care delivery, and overall health and wellness. 

GenAI voice agents are poised to revolutionize outbound calling in the healthcare industry. By leveraging a variety of advanced LLMs, AI-powered voice agents can significantly improve efficiency, member engagement, overall operational outcomes, and understanding of healthcare costs. 

Zaffar Khan is Associate Vice President of Business Transformation & Generative AI Solutions at Sagility.

This article originally appeared in Healthcare Contact Center Times.

Sagility acquires BroadPath Healthcare Solutions, a US healthcare focused services company

Sagility aims to accelerate growth in the mid-market payer segment with this acquisition

Bengaluru, India. Sagility, a leading tech-enabled business operations solutions and services provider in the healthcare sector, today announced its acquisition of BroadPath Healthcare Solutions, a US healthcare focused services company, headquartered in Tucson, Arizona, US. BroadPath operates a work-from-home delivery model with over 1600 employees located across the US and Philippines. Its service portfolio includes member engagement, member acquisition, claims and appeals administration, provider enrollment and credentialing.

The acquisition of BroadPath aligns with Sagility’s strategy to diversify its client base and add new capabilities to its services portfolio. This acquisition significantly expands Sagility’s market presence, adding more than 30 new clients. It further strengthens Sagility’s position among the top ten largest health plans in the US. In addition, the acquisition gives Sagility the opportunity to cross-sell its broad service offerings to several mid-market clients including payers, third-party administrators, pharmacy benefit managers and providers. BroadPath’s member acquisition services will be a new capability addition to Sagility’s offerings. 

BroadPath has been a pioneer in the work-from-home model even before the COVID-19 pandemic. Their proprietary Bhive platform improves employee engagement and optimizes operating metrics in a work-from-home model ensuring superior experience for employees and clients alike.

“We are very excited to add a sizeable number of clients through the acquisition of BroadPath. Their unrelenting focus on clients and employees aligns well with our beliefs and we are confident of seamlessly integrating BroadPath’s clients and employees into our larger organization. The strong operating leadership team at BroadPath, with deep relationships across health plans, will remain with the business and continue to drive success for clients.”, said Ramesh Gopalan, Managing Director and Group Chief Executive Officer of Sagility.

“Our clients will benefit from the opportunity to utilize the broader set of services and transformational capabilities that Sagility offers. Sagility brings advanced capabilities such as automation, analytics, and artificial intelligence which will enable our clients to further drive efficiencies and improve member engagement.” said Don Hubman, Chief Executive Officer of BroadPath Healthcare Solutions.

About Sagility

Sagility is a tech-enabled, US healthcare-focused business operations solutions and services company that supports payers, providers, and their partners in delivering best-in-class operations, enhancing member and provider experiences, and improving the quality of care, all while ensuring cost-effective financial and clinical outcomes. With over two decades of experience, Sagility’s dedicated experts address complex healthcare challenges through deep domain expertise and technology innovations. The company serves five of the top ten payers in the U.S., utilizing its advanced technology, processes, and solutions to ensure efficient operations and minimize additional administrative costs. The company delivers these services through its skilled talent pool of over 38,000 professionals across five global service delivery centres located in the US, India, the Philippines, Jamaica, and Colombia.

www.sagilityhealth.com

Protecting Healthcare Data, Improving Trust Through Security Measures

January 2, 2025 – (Security magazine)

Data security is of paramount concern to all healthcare organizations. In today’s digital age, protecting sensitive medical information is not just a regulatory requirement but a cornerstone of trust and business integrity. There are ways to mitigate data breaches and create an environment where healthcare organizations and the companies that support them can thrive and provide important healthcare services.

Article originally published in Security magazine

Why As-a-Service Solutions Benefit Payers with New Insights

December 16, 2024 – (HealthCareBusiness News)

With ever-increasing pressure on profitability and medical loss ratios, healthcare payers face tight budgets, a continued need to increase productivity, lower costs, enhance technology, and reinforce IT infrastructure while improving the healthcare consumer experience.

Article originally published in HealthCareBusiness News

 

The Triadic BPaaS Model: Optimizing Efficiency, Building Experience for Health Plans

December 12, 2024 – (HealthCare Business Today)

The healthcare industry is constantly evolving and health plans, in particular, face numerous challenges ranging from regulatory changes to rising operational costs. In this changing landscape, health plans may not have a clear vision of the course needed to navigate the continuous evolution of the healthcare system successfully.

Article originally published in Healthcare Business Today

AI Trends Transforming Health Care Contact Centers in 2025

December 9, 2024 – (Integrated Healthcare Executive)

The healthcare contact center landscape is undergoing a revolution, driven by rapid advancements in artificial intelligence (AI). These cutting-edge technologies are reshaping how interactions are managed and enabling more efficient workflows, personalized experiences, and proactive solutions.

Article originally published in Integrated Healthcare Executive

Should Patients Share Their Medical Records to Improve AI Models?

November 24, 2024 – (HealthCare Business Today)

Would you contribute your medical records to an organization dedicated to improving healthcare worldwide if the data were anonymized and used for the “greater good”? To benefit humanity? Generative AI models could be made more effective with larger healthcare information datasets. Individuals could consider contributing their healthcare data for such purposes if assurances are provided that data would not be misused.

Article originally published in Healthcare Business Today

Transforming Contact Centers into Innovation Hubs: The Role of AI in Creating New Opportunities

October 20, 2024 – (HealthCare Business Today) –

Transforming Contact Centers into Innovation Hubs: The Role of AI in Creating New Opportunities.

Unquestionably, the contact center has a front row seat to generative AI (GenAI) in the workplace. Traditionally seen as cost centers focused on customer service, contact centers are now poised to become innovation hubs. This transformation is driven by AI, which is not only automating routine tasks but also creating new roles, augmenting existing ones, and reskilling agents for future-ready positions

Article originally published in Healthcare Business Today

 

Achieving Payment Integrity Precision in the Age of AI

October 7, 2024 – (HealthCare Business News) –

For healthcare, artificial intelligence promises improved member experience, quality, and economic opportunity for health plans. How is AI delivering on the promise? According to McKinsey research, with technology including AI, payers could experience net savings of 13 to 25% in administrative costs and 5 to 11% in medical costs as well as 3 to 12% higher revenue.

Article originally published in HealthCare Business News

 

Connecting the Healthcare Lifecycle: Administrative Services to Clinical Operations

October 7, 2024 – (Forbes Business Development Council) –

Undoubtedly, healthcare experience delivery is getting increasingly intricate. From front and back office to clinical, operational excellence that connects points of service is more important than ever. Value stream undercurrents include both the influence of tech enablement like GenAI and consumer expectations. Members and patients are now expecting more, with digital tools raising the bar for experience. When healthcare services partners step in to bridge these gaps, the benefits are multiplied—with better efficiency and care for everyone involved.

Article originally published in Forbes Business Development Council

Reimagining the Healthcare Contact Center: The Impact of Generative AI on Payers and Providers

August 30, 2024 – (Call Center Times) –

Healthcare payers and providers are increasingly challenged to raise the bar for consumer experience. And tech enablement is essential to realizing the evolving value propositions. On the front lines of experience and engagement, contact centers are set for a profound transformation. Generative AI (GenAI) and agentic learning systems are evolving to operate with greater autonomy and adaptation through continuous feedback. These disrupters are now driving the contact center shift—from traditional, reactive service hubs into proactive, intelligent coordinators that bridge the gap between payers, providers, and patients. GenAI, as key enabler, promises to streamline complex healthcare workflows, enhance collaboration, and deliver more personalized and efficient services.

Article originally published in Call Center Times 

How GenAI Solves for Challenges in the Healthcare Front Office

September 26, 2024 – (HIT Consultant) –

While in recent years healthcare has made significant strides toward optimizing the customer experience, the industry is now at an inflection point with the adoption of generative AI (GenAI). With its highly trained and expensive talent and mountains of unstructured data, healthcare is uniquely suited to leverage GenAI to drive productivity and an improved consumer and employee experience. In fact, according to McKinsey, healthcare companies could unlock up to $1 trillion in value by applying GenAI solutions to unstructured data.

Article originally published in HIT Consultant 

Meeting the Aging-in-Place Member at Home

September 26, 2024 – (McKnight’s Home Care) –

Older people are hoping to spend their golden years in a familiar and comfortable place — their home. According to a 2024 2024 survey conducted by US News & World Report, 93% percent of United States adults ages 55 and older view aging in place in their homes as an “important goal.” Projections from the US Census Bureau indicate that the number of Americans who reach the age of 100 (and older) will quadruple over the next three decades. The aging population creates a growing need for focused aging in place services.

Article originally published in McKnight’s Home Care

Enhancing Provider Experience through Electronic Prior Authorization

August 13, 2024 – (First Report Managed Care) –

Each year the American Medical Association (AMA) surveys its membership to ascertain their feedback concerning prior authorizations (PAs) and the impact of this service on their practice. Reliably, AMA members say that PAs are disruptive to their practice, resulting in higher cost to the entire health care system as well as impact to patient care. Yet the insurance industry is at a crossroad as to where technology can provide immediacy to minimize the abrasion many practices endure daily. The key to this is how.

Article originally published in First Report Managed Care

 

Sagility Wins Bronze in the Stevie® Awards for Employer of the Year

Sagility is proud to announce our most recent accolade:

Bronze in the Stevie® Awards for Employer of the Year − Health Products & Services

Our nomination highlighted Sagility’s significant employee satisfaction increases and commitment to our Voice of Employee feedback and leadership action planning.  Sagility also found a client benefit in a correlation between ESAT and customer satisfaction (CSAT) scores.

“It is an honor and testament to our strong and best-in-class employee practices to have been awarded this Stevie Award. At Sagility, we constantly listen to our employees and act on feedback that directly impacts their well-being and, ultimately, organizational performance. We’ve built a culture in which our business leaders are as focused on driving eNPS as they are on client NPS, because we understand the direct correlation.”

Tina Vas
Senior Vice President – Global Head of Human Resources

The Critical Imperative for Health Plans to Tackle Late Payment Interest

August 07, 2024 – (MedCity News) –

Today’s health plans continue to pay healthcare providers significant penalties and interest when they violate prompt pay laws for clean claim-delayed processing due to various processes, disparate systems, and dependencies on functional groups. This includes, for example, authorization requirements, coordination of benefits details, external pricing, provider data management, itemized bills, and medical records requirements. In fact, major payers have paid $150 million to $60 million in penalties annually and are estimated to pay an additional 20% to 30% every year. More specifically, as the cost of working capital is increasingly a focal point, so is the need for cost avoidance and improving operating cash flow issues.

Article originally published by MedCity News

 

Payer-Provider Synergy: Aligning at the Fulcrum Points

August 5, 2024 – (First Report Managed Care) –

In recent years, the health care industry has experienced unprecedented change. Tech enablement, strategic service offerings, value-based care initiatives, and data sharing mandates have converged with the goal of creating a system that is member/patient-centered and outcomes-based, while also lowering the overall cost of care. It is now widely understood that the member/patient is increasingly demanding better and more transparent payer-provider collaboration. In fact, 83% of patients in a recent Physicians Foundation survey called for better communication between physicians and health insurance plans.

Article originally published in First Report Managed Care

 

Easing the Nursing Shortage Burden With Wins on Quality, Cost, Scale

July 10, 2024 – (First Report Managed Care) –

Already challenged with cost, care, and administrative pressures, health care organizations are now staring down a daunting talent supply-and-demand gap. This shortage will negatively affect affordability and access to care for consumers and bears profitability risks for providers, payers, and other health care stakeholders.

Article originally published by First Report Managed Care

Information Security and Compliance: Solving for 3 Security Pain Points

June 21, 2024 – (Medical Economics) –

Information security and compliance are the bedrock of trust in the digital age. Not only do they safeguard data and avoid potential financial losses, but they are the very essence of our integrity and reputation. And although primary care physicians, payers and providers are especially busy right now, they cannot afford to neglect cybersecurity and data protection. Without stringent measures in place, health care organizations are exposed to unprecedented risks, jeopardizing not only their assets but also those of their members and patients.

Article originally published in Medical Economics

 

Star Ratings Success: Making it about the Customer

May 31, 2024 – (Healthcare Business Today) –

New ratings methodology has raised the bar for healthcare Star success, so it’s a good time to redefine what high Star ratings means to the members. This means connecting the dots of experience for satisfied members and true value creation for respective Medicare plans. Health plans can meet upgraded expectations with focus beyond customer service—as supported by healthcare domain knowledge and a high-touch experience across three critical areas: Claims, Medical Management, and Provider synergies.

Article originally published by Healthcare Business Today

4 Ways to Mitigate Breaches and Security Crises in Healthcare

May 07, 2024 – (First Report Managed Care) –

While today’s healthcare payers and providers are increasingly turning to tech enablement to drive efficiency and reduce labor costs, there are conflicting pressures and demands. Complex regulations challenge business as usual, with an ever-higher bar for improved member-patient experience to compete in the marketplace—all in the face of shrinking operating margins. Add to these everyday struggles an emerging threat: a debilitating assault by cybercriminals that can force software providers offline and disrupt automation, impacting insurance verification, prior authorization, and billing, in an instant.

Article originally published in Health IT Answers

3 Ways Prior Authorization Transformation will Change Health Care

April 1, 2024 – (Medical Economics) –

Prior authorization (PA) has long been a care and coverage bottleneck for all involved—patients, members, providers, and payers. What’s been needed is structure to connect all stakeholders and systemize the process. In January 2024, the Centers for Medicare & Medicaid Services (CMS) finalized requirements to streamline the prior authorization process; this proposed requirement will be enacted in January 2026. This new regulation aims to shorten the timeline for the prior authorization process to immediate or as little as 72 hours for individuals who get their health insurance through Medicare Advantage, Medicaid, or a Qualified Health Plan on the exchanges by automating prior authorizations at the point of care.

Article originally published by Medical Economics

 

 

Sagility Acquires BirchAI, a GenAI Company in the Healthcare Space

Sagility to transform member, patient and provider interactions using BirchAI’s SaaS platform

DENVER, COLO. – March 26, 2024 – Sagility LLC, one of the leading technology-enabled services providers in the healthcare services space, announced its acquisition of Seattle-based BirchAI. BirchAI is a healthcare technology company offering cloud-based, GenAI call technology built by experts in transformer-based natural language processing. BirchAI enables clients to reduce operational costs by providing various AI-powered real-time customer support solutions to manage complex healthcare transactions. 

Ramesh Gopalan, Sagility’s Group CEO noted, “We’re thrilled to announce this acquisition of BirchAI, which enables Sagility to build on our healthcare domain expertise and demonstrates our commitment to technology enabled transformation of the healthcare value chain. BirchAI’s generative AI capabilities will help us deliver significantly more impactful ROI to our clients.” 

With this acquisition, Sagility broadens its analytics and automation backed healthcare engagement services that it provides to large national payers, Blues plans, regional payers, health systems, medical devices and other healthcare providers. 

BirchAI will further propel Sagility’s delivery of healthcare operations, enhance the member and provider experience, and improve quality of care. “Sagility brings strong domain expertise and a renowned healthcare presence to complement our generative AI solutions,” noted Kevin Terrell, Cofounder and CEO, BirchAI.

Sherman & Company served as BirchAI’s financial advisor on the transaction. 

About Sagility

Sagility combines technology and transformation-driven healthcare services with decades of healthcare domain expertise to help clients draw closer to their customers. The company optimizes the entire member/patient experience through service offerings for clinical operations, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 34,000 employees across 5 countries.

Visit www.Sagilityhealth.com to learn more. 

About BirchAI

BirchAI is a GenAI company founded in 2020 by Kevin Terrell, Sumant Kawale and Yinhan Liu. The concept was developed through Seattle’s AI2 Incubator, one of the world’s leading supporters of AI-first startups.

BirchAI helps their clients reduce average handle time by up to 35% by automating complex healthcare interactions using proprietary speech-to-text and Large Language Models that efficiently integrate with most commonly used CCaaS and CRM solutions. 

Visit https://birch.ai to learn more. 

Media Contact
Sohail Djariri
Chief Growth Officer,
Sagility
[email protected]
+1 602-502-9536

Addressing the Public Health Toll of Falls

March 7, 2024 – (McKnight’s Home Care) –

Right before Thanksgiving, Sharon, 80, was home alone when she slipped on some flour that had spilled on the floor. Her daughter, Sally, arrived a short time later and found her sitting in a chair in an odd posture, shaken by the event and not wanting to be left alone. A subsequent trip to the doctor was unrevealing, but the after effects of the fall were dramatic. Sally said her mom “seemed mentally stunned and unresponsive,” needing help with most daily activities for weeks.

Article originally published in McKnight’s Home Care

 

Fiscal Health for Providers: Precision Cost Takeout in Three Areas

February 17, 2024 – (Healthcare Business Today) –

As today’s hospital margins are increasingly in the red, and health systems are asked to do more with less, all eyes are on cost removal. According to a survey on healthcare outsourcing conducted by Black Book Market Research LLC, 90% of healthcare executives are exploring cost savings through relationships with third-party vendors. 

Article originally published by Healthcare Business Today

Unlocking 4 Areas of Provider Network Value in the Wake of Surprise Billing Mandates

January 15, 2024 – (MedCity News) –

Today’s payers are still adjusting to the significant operational and transparency changes as a result of the No Surprises Act and Consolidated Appropriations Act. These mandates put the provider network operation on the front line and at the eye of the storm of some pressing market conditions—from the regulations to escalating, costly labor challenges and damaging provider abrasions that can easily build to member abrasions. The inherent network database inaccuracies shouldn’t be underestimated as just operational and physician satisfaction bottlenecks. These discrepancies can prevent patients from accessing the care they need, leading to poor health outcomes and satisfaction levels. Additionally, the spotlight is now even brighter with recent No Surprises regulations requiring providers and payers to keep patients informed about the costs of care and their personal financial responsibility throughout the care journey.

Article originally published in MedCity News

 

4 Ways to Win with Claims Denials

January 2024 – (Health IT Answers) –

Facing both revenue and expense issues and exasperated by clinician shortages, hospitals are increasingly noting denials in the danger zone. “Danger zone” translation: Denials are increasingly higher than 10%, costing significant dollars in lost or delayed reimbursements – as well as more overhead for rework and resubmitting claims. A recent Crowe RCA benchmarking analysis provided the industry-wide numbers: Claims denials rose to 11% of all claims last year, up nearly 8% from 2021.

Article originally published in Health IT Answers

 

Solving Health Care’s End-to-End Challenges With Generative AI

December 04, 2023 – (Integrated Healthcare Executive) –

Health care can no longer afford to ignore tech disruption and enablement. From disparate data sources across multiple stakeholders to tedious, error-prone operational tasks, the industry’s challenges are uniquely suited to transformation driven by generative AI. Every day, the industry increasingly embraces these disrupters, with breakthrough transformation examples like AWS HealthScribe for clinical transcription and Epic integrating GPT-4 into its electronic health record.

Article originally published by Integrated Healthcare Executive

BPO, Supercharged: Business Process as a Service Drives Scale, Savings While Exponentially Enhancing Outcomes

October 5, 2023 – (Healthcare Business Today) –

Discover how BPO is no longer just about cost-cutting; it’s a supercharged strategy that drives scalability, savings, and, most importantly, unprecedented outcomes. Find out more in our blog/article, “BPO, Supercharged: Business Process As A Service Drives Scale, Savings While Exponentially Enhancing Outcomes,” by Sagility team members Srikanth Lakshminarayanan, Umesh Chandorkar and Nikki Henck.

Article originally published by Healthcare Business Today

Press Release: Sagility LLC Acquires Devlin Consulting, Inc.

DENVER, April 25, 2023 08:00 AM Eastern Daylight Time – (BUSINESS WIRE) – Sagility LLC, a leading provider of technology-enabled business process management (BPM) services, announced today their acquisition of Chandler, Arizona-based Devlin Consulting, Inc. (DCI). For the past 28+ years, DCI has made a name for itself as a healthcare technology services company providing payment integrity services to several of the country’s leading health plans.

With this acquisition, Sagility broadens the 360-degree precision payment integrity solution offering they provide to five leading US health plans and regional Blue plans. Sagility’s payment integrity services are backed by 18+ years of payer and claims expertise with certified coders/credentialed clinicians, data scientists, claims examiners, and auditors.

This union combines Sagility’s payment integrity solutions and advanced analytics with DCI’s robust contract central technology platform. Through this relationship, Sagility will now offer market-leading payment integrity solutions suite that focuses on pre-pay cost avoidance, enhanced post pay recoveries, and improved provider-payer relations. These features will help clients achieve the new levels of efficiency required to thrive in today’s marketplace.

“Sagility has outlined a strong growth trajectory, and one of the key strategies fueling this is the acquisition of credible companies that further strengthen and complement our capabilities,” said Ramesh Gopalan, Group CEO of Sagility. “With the integration of DCI’s expertise, we will further enhance our payment integrity offering while remaining committed to all areas of client service excellence.”

About Sagility

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical operations, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Colorado-based Sagility has more than 30,000 employees across 5 countries and revenues of over $500 million.

About Devlin Consulting, Inc

Devlin Consulting Inc. (DCI) is a payment integrity firm which utilizes specialized technology to shorten the time horizon from overpaying a claim to the time it is identified and client systems can be updated to help avoid future payment errors. Founded in 1995, DCI’s payment integrity services provide millions of dollars of post payment overpayment identifications for clients. DCI has extensive experience in the health care field with over 28 years of experience servicing managed care clients. Synergy Advisors acted as exclusive financial advisor to DCI in this transaction.

Transformative AI to Revamp Prior Authorizations

Tech enablement drives lower costs, lessened provider abrasion

Health plans are unnecessarily burdened by administrative tasks such as prior authorization—a costly bottleneck to optimized care and operational outcomes. Recent American Hospital Association (AHA) research states that that 95% of providers spend increasing time seeking prior authorization approval. An astounding 78% of hospitals and health systems said their relationship with commercial insurers is getting worse. What’s needed is relief at this high-impact payer-provider touchpoint. AI-enabled prior authorizations can help. According to McKinsey analysis, AI-enabled prior authorizations can automate up to 75% of manual tasks. This tech enablement solves for many of the inefficiencies while working to improve payer and provider synergy, reduce costs, improve case turnaround time, and, most importantly, drive better health outcomes for patients.

Drivers to Digital Utilization Management

The case has never been clearer for a straightforward, faster, and impactful PA process. High-impact PA ups the ante with an analytical approach to flag clinical decisions that need priority nurse review. The algorithmic decision support can identify high dollar clinical usage patterns, FWA patterns and CPT conversion/alternative treatment. Traditional, siloed UM programs are not adequate to meet current market conditions: a high-cost clinical resource pool and financially pressured payers and providers. Add to that this simple fact: our internal research shows that 80+% of authorizations reviewed are eventually approved without any modifications, and only a few of the cases need a detailed review for necessity. This leaves a lot of room for digital intervention in the provider interaction channel to instantly auto-approve and provide an outcome via digital assists for better member care.

Experts such as healthcare business process management partners have the combined digital solution and skillset: experienced clinicians supported by AI workflows to effectively manage the process and cost. Backed by process re-engineering, automation and digitization of the prior authorization process will ease provider burnout and change the perception of this process. Traditionally, the prior authorization step has been viewed as cumbersome, with high administrative costs running into billions of dollars across the US healthcare sector. BPM partners with experience across both payers and providers can collaborate and bridge gaps to improve the overall ecosystem of population health and give a better dollar accountability and visibility. As a result, transformed, high-value utilization reviews will drive to lower-cost per review using state specific/CMS guidelines and a 99%+ calibration with medical directors on review decisions.

UM Augmented with Transformation Levers

The front- and back-office digital suite of solutions use automated speech recognition (ASR), NLP of medical entities, contextual insights, computer vision, and machine learning feedback to evaluate prior authorization requests against automated guideline rules. The outcomes are provided via digital nurses on some channels and nurse assist flows on others, each with comprehensive criteria summary and recommendation on approval or referral to a medical director.

Outcomes and Future of Clinical Reviews

BPM partners with experienced clinical resources combined with AI workflows can manage the PA process cost effectively and find transformation with process effectiveness. For the first launch of the back-office solution for a top payer client, Sagility’s prior authorization medical record review automation leveraged in-house asset Intelligent Content Processing (ICP) for a 20% efficiency gain across the entire document review process, with a line item gain of 75% error reduction, in some cases. With the buildup of this platform to transform clinical data into intelligence to reduce process complexity, enhance accuracy, and speed TAT which is 7-10 minutes saved per case transaction. Through machine learning, these savings will compound over time, for up to 40% cost savings for identified scenarios. This powerful tool will also drive significant TAT improvements as well as enriched provider and member experience (potential Star and NPS ratings impact) from improvements on quality with reduction in nurse error and nurse glide path, enhanced productivity, decrease in regional medical director (RMD) routes, increase in identification of potential approvals for nurse to review and also decrease in number of cases referred to physician.

Transforming the front office with the voice assist and context bots results in auto-approvals for high volume procedures. This directly reduces call volume reduction by 10-15%. The next-best action and access to unified knowledge bases have driven a shortening of complex prior authorization calls, for 15-20% savings via handle time reduction. The continuous digital bot and agent monitoring metrics have also resulted in an internal training glide path reduction by 50%, ensuring the quality of outcome at above 99%+. Overall savings in the front office can be at least 20% as skilled resources need no longer work on administrative tasks anymore.

As next steps, any outcomes of clinical decision support that sources from a unified data lake of claims, medical records, and member profiles can be successfully linked with population health outcomes and patient profile stratification. This will result in insights on high risk population analysis, population trends and wellness management, and, finally, risk scoring of individuals and proactive population management. Weaving in provider profiles can also help provide in extension insights on the segmentation, scorecards, and comparative analytics to evaluate provider utilization and abuse, if any.

As published on Healthcare Dive

Challengers of the Status Quo In Billing and Claims — More Accurate and Fairer Payment

This coverage demonstrates Sagility’s thought leadership on the potential for dramatic change in an area that’s long been an issue for health insurance plans.


Article originally published by Managed Healthcare Executive

Author: Sohail Djariri, Chief Growth Officer, Sagility

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