Agentic AI for Payers
Reduce Administrative Costs, Accelerate Decisions, and Improve Member Experience
Automate prior authorization, claims review, provider data management, member support, and compliance workflows with domain-specific healthcare AI.
Why Payers Need AI-Driven Operations Automation
Health plans, TPAs, and risk-bearing organizations face massive administrative burdens:
Prior authorization delays create provider dissatisfaction
Manual PA reviews slow care delivery and strain provider relationships.
Claims review requires high-cost labor and manual decisions
Human review of every claim is expensive and time-consuming.
Provider data is fragmented across systems
Inconsistent and duplicate records create operational inefficiencies.
Member call centers are overwhelmed
High call volumes for routine inquiries strain resources and reduce satisfaction.
Compliance audits demand extensive documentation
Manual evidence gathering for audits is slow and error-prone.
Operating costs continue to rise despite modernization efforts
Traditional automation hasn't delivered the promised efficiency gains.
How Agentic AI Improves Payer Operations
Reduce costs, improve member satisfaction, and accelerate decision-making
Prior Authorization Automation
- Extracts clinical information from submissions
- Auto-categorizes cases and drafts determinations
- Flags missing documentation and inconsistencies
Claims Review & Adjudication Support
- Pre-processes claims to detect rule violations
- Identifies high-risk or high-cost claims
- Reduces manual review workload
Provider Data Automation
- Cleans, validates, and updates provider data
- Eliminates duplication and inconsistent records
- Monitors changes in directories, credentials, affiliations
Member Support Automation
- AI agents handle benefits questions, PCP updates, ID card requests
- Integrates with portals and call centers
Compliance & Audit Automation
- Extracts evidence for audits
- Generates structured audit-ready packets
- Tracks documentation timelines automatically
ROI of Agentic AI for Healthcare Payers
Measurable improvements across operations, member experience, and provider relations
reduction in administrative operational costs
prior auth processing → improved provider relations
claims error rates and fewer appeals
call center burden → higher member satisfaction
compliance accuracy and audit readiness