Five AI Use Cases for Healthcare Payment Providers

Table of contents Introduction.03I.Chronic condition management and remote patientmonitoring enrollment.04II.Medication adherence and post-discharge follow-up.06III.Benefits, education, and plan selection support.08IV.Benefits, eligibility, and quoting assistance.10V.Claims inquiry automation and status transparency.12Impact: Delivering connected care at scale.14Conclusion.15 Introduction. Healthcare payers operate at the intersectionof rising member expectations, relentless costpressure, and expanding regulatory scrutiny. This ebook explores how healthcarepayers are using Agentic AI to move fromreactive service to proactive, personalizedengagement across the member journey.For healthcare payers, these interactions consistently across every channel and interaction.They expect the speed of automation withoutsacrificing personalization, empathy, or trust.Every interaction, from chronic condition outreachto claims questions, shapes trust and Star Ratingsoutcomes. AI agents are changing payer operations I. Chronic condition managementand remote patient monitoring More than 6 in 10 U.S. adults live with at leastone chronic condition, making proactiveengagement and long-term adherencecritical priorities for healthcare payers.Agentic AI enables proactive, personalized Solution Challenge Payers know chronic conditions such as diabetes,hypertension, and heart disease create recurring coststhat compound over time. The problem is not awareness;it is execution at scale. Traditional care management relieson limited staff to make outbound calls, leaving many eligiblemembers unreached, unmotivated, or confused about the A customer experience automation (CXA) solution shiftschronic condition outreach from episodic campaigns tocontinuous, context-aware engagement. These workflows canalso support quality improvement initiatives tied to medicationadherence, preventive care, and member engagement validates details, coordinates delivery, schedules training,and documents the interaction. If it detects risks, theworkflow routes to a human with full conversation context.Interaction and Quality Analytics then reveal which systems to confirm eligibility, document consent, scheduledevice training, or arrange delivery. That friction increaseshandle time, drives abandonment, and blocks enrollment.The result is missed opportunities to stabilize conditions II. Medication adherence andpost-discharge follow-up. AI can reduce working hours by up to 44%by optimizing follow-up after discharge.Gaps like missed refills or side effects leadto complications, while AI triages risks Solution Challenge Medication adherence touches outcomes, quality measures,and cost, yet payer operations struggle to influence itconsistently. Many plans depend on reminders that do notadapt to the member’s real barriers, confusion, transportation Automating the customer experience allows payers to standup an adherence workflow that blends proactive outreachwith on-demand support. An AI agent checks in afterdischarge, confirms whether prescriptions were picked up,and offers refill support, mail order enrollment, or ninety-day prescription go through?” and “Can I switch to mail order?”questions, while nurses and pharmacy teams focus on higher-acuity cases. Fragmented systems make it difficult to seerefill history, member preferences, and prior conversations conversations with next best actions and real-time guidance,reducing handle time while protecting empathy. Omnichannelcontinuity keeps the thread intact across phone, shortmessage service, and chat. Analytics surface recurring III. Benefits, education,and plan selection support. Enrollment periods create sharp spikes inmember inquiries, increasing pressure on payercontact centers to deliver fast, accurate, andcompliant guidance at scale. During open Solution Challenge Benefits guidance becomes difficult when complex decisionscollide with enrollment deadlines, rising volumes, andfragmented engagement channels. During enrollment peaks,contact centers face surging volumes and longer waits, andmembers abandon digital tools that feel like rigid forms.Many questions are context-heavy: “I’m moving,” “My spouse Payers must deliver consistent, compliant enrollmentguidance at scale. AI-powered workflows can guide membersthrough benefits and enrollment questions using naturallanguage conversations that adapt to individual needs and workflow seamlessly routes to a licensed agent and passesfull context, including what the member already asked andwhat the AI already explained. A knowledge managementsolution supports accurate, accessible answers, reducing channel they use or the representative they reach. Agentsspend time searching policy documents, repeating basicdefinitions, and correcting misunderstandings rather thanhelping with decisions. Compliance adds friction becausesome conversations must route to licensed agents, and IV. Benefits, eligibility, and quoting assistance. Benefits and eligibilit