Health plans are getting squeezed from several directions at once. Administrative costs press against the medical loss ratio ceiling, new prior authorization rules set binding turnaround times and require public denial reporting, and members and providers expect answers in minutes.
Underneath it all is the same operational layer: high-volume, manual back-office work. This e-book maps where AI and agentic automation create the most value across the five payer workflows where it concentrates — medical records summarization, claims intake, prior authorization, appeals and grievances, and enrollment and benefits. Each one includes the operational math, the compliance implications and outcome ranges from real deployments. It closes with an agentic operating model and a practical place to start.
Inside, you’ll find:
- Where the $265 billion in annual U.S. healthcare admin waste sits in payer operations, and which workflows pay back first
- What an audit-ready operating model looks like — where people stay in the loop, how decisions stay traceable and how plans get past pilots into production
- How agentic automation compresses prior authorization cycle time ahead of the CMS Interoperability and Prior Authorization rule, with clinical reviewers still making every determination
- Why a high overturn rate on appealed claims signals a rework problem that starts at intake, not adjudication