Transforming healthcare: the chatbot will see you now

Conversational AI platforms like ChatGPT, Google BARD and Meta OPT are sophisticated language models that are built on a massive corpus of language, so their conversation is human-friendly, actionable and logical.

As AI adoption is gradually increasing in healthcare, a chat platform can be transformational to payer, provider and health services business operations in five key areas:

  • Driving member and patient experience: Many consumers today struggle to understand and navigate the healthcare system (e.g., understanding explanation of benefits or identifying the right provider). Conversational AI-enabled solutions can be digital front doors for the member and create a personalized experience serving as a virtual health assistant, summarizing benefits in layman’s language, providing assistance in tracking claims status, identifying coverage options and generating personalized health recommendations. Investments in this chat capability can help payers and providers keep up with their patients and shift care to a prevention-based model.
  • Facilitating patient communications and supporting contact centers: Clear and easy to understand communication is essential in healthcare. The use of deep learning enabled language models can help provide patients with the care they need by enabling real-time interactive conversations across a range of services, from explanation of benefits (EoB), scheduling appointments to filling prescriptions to answering questions 24/7. An example is customer contact centers where chat capabilities are embedded in a workflow and can answer and resolve the bulk of customer queries, freeing up resources to handle more complex cases. Among other benefits, this can also have a direct impact on key operational metrics such as first call resolution, which can, in turn positively impact quality and STAR ratings.
  • Streamlining operations and improving productivity: Conversational AI chat models can be integrated with payer administrative and clinical systems and workflows to drive gains in efficiency and effectiveness. Some examples include automating routine tasks such as data entry, customer service inquiries, generating denial or acknowledgement letters to more complex tasks such as identifying patterns in data including gaps in care and producing actionable and personalized insights to improve member health outcomes. The potential for this technology is such that the bulk of the operations in many areas could be automated, with a lean human workforce that is involved in the final step around editing and making final decisions.
  • Providing strategic guidance: As the capability matures, conversational AI models can not only help with streamlining operations, but also guiding payers or health systems in making key strategic decisions. For example, with proper training, a tool can scrape vast amounts of web and social media data to identify patterns and provide summarized actionable recommendations for competitive positioning.
  • Aiding in clinical decisions:Advanced AI chat models can augment human decision-making on the clinical side. For example, they can identify patterns and trends in data, conduct cost-benefit analysis to evaluate effectiveness of different treatments, and write medical policies. They can also assist in automating the process of documenting and coding patient information, which can help providers make more accurate and efficient decisions. Other examples where advanced AI chat models can support clinical decision making include summarizing medical literature to help providers stay abreast on latest scientific and technological developments, assisting in triage to prioritize resources and suggesting alternate diagnoses to help providers narrow potential conditions quickly.

There are often step changes in technology that change the art-of-the-possible in healthcare. The electronic health record, internet, browsers, smartphones, social networks and cloud technology are some of these.  We expect that conversational AI using generative AI will be one such transformative technology. Companies that can harness the power of this technology can reap significant operational and financial benefits while elevating member experience and health outcomes.

Contact :

Ravi Kalakota, Managing Director, PwC, US

Srikumar Murthy, Director, PwC, US

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