Many of us have experienced the frustration of waiting long hours to get a patient slot at a clinic or hospital. Let us imagine a situation where policyholder Jane faces a delay in the diagnosis of acute appendicitis. This delay results in limited treatment options, days of clinical examination, additional hospital admissions, and additional medical procedures such as preoperative blood tests, X-rays, and colonoscopies. Poor pain management and confusing discharge instructions further worsened her condition and took an emotional toll. Despite having comprehensive insurance, Jane received claims that were far less than her medical bills, leaving her frustrated and dissatisfied with the entire process of care.
Jane’s situation is not unique in the insurance industry. According to Accenture research , 24% of global consumers Unsatisfied with their health insurance claims experience. In this blog, we take a closer look at the health insurance claims experience in Asia Pacific, with China and Japan reporting higher dissatisfaction rates at 39% and 41% respectively. Unfortunately, Many insurers employ conservative claims cost management strategies driven by legacy technology, limiting the full utilization of available data, including historical context and patterns. This is starting to change, but slowly. 45% of insurance companies have deployed claims processing using Gen/AI as a strategic bet, but only 12% of insurance companies have deployed and scaled it up. This often results in evaluators manually piecing together fragmented information, resulting in less informed and accurate decisions, resulting in inconsistent claims assessments. These challenges highlight the urgent need for a transformative approach to health insurance claims management. However, as we Beyond Transformation Euphemisms The term “transformation” has become a catch-all term for insurance companies in the report, and not all change initiatives are created equal. The stakes are high. Those high-performing insurance companies, if they make the right changes, will see an average increase in premium income of 8.1 percentage points and a reduction in expense ratios of 2.6 percentage points. Therefore, a very thoughtful and precise claims management strategy is required, involving core platform modernization and the use of AI agents, which we outline below.
Modernizing claims platforms is a strategic imperative
To attract and retain policyholders like Jane, it is paramount for health insurers to not only embed accuracy, speed and explainability into the claims management process but, crucially, embody empathy. Platform modernization and collaboration with healthcare providers creates a connected healthcare ecosystem while combining advanced artificial intelligence with modern processes and strategic partnerships to enhance decision-making and deliver consistent, timely and accurate claims. We will now expand the use of AI agents, which are critical to ensuring customer experience is paramount with empathy.
Unleashing the potential of genAI in claims management: Super Agents + Utility Agents
In conjunction with platform modernization, to accelerate future-proof claims operations, insurance companies should leverage agent AI for rapid deployment. agent artificial intelligence are “artificial intelligence agents” that exhibit human-like behavior and interactions, operate independently using internal models, learning algorithms, and decision-making capabilities, and unlike traditional AI systems, require lower levels of human intervention. The genAI claims agent framework is built around two key roles in the workflow: Super Agent and Utility Agent.
super agent Leverage genAI to enhance the claims experience with automated and digitized intake, case summarization, verification and adjudication, and analytics-driven fraud, waste and abuse detection embedded throughout the process.
on the other hand, utility agent Focus on extracting and validating data from documents to provide evaluators with actionable insights while monitoring performance.
With advances in genAI and agent AI, insurance companies can use AI models to extract information from legacy technology stacks to enhance claims decisions through summarization and synthesis without requiring radical changes to the technology stack, operations, and architecture.
Connected customer healthcare for treatment and prevention: online and offline convergence
In Jane’s case, early diagnosis would not only impact her health outcomes but also significantly reduce her medical costs and treatment time. The healthcare journey should start from the moment she feels unwell and requires a comprehensive approach to delivery. Close collaboration and information sharing between patients, healthcare providers, insurance companies and other stakeholders in the healthcare ecosystem is critical. Insurers can play a key role by driving seamless online-to-offline health and wellness services. With their resources, data and strategic positioning, they can expand their preferred care network, provide patients with more choices and improve claims cost visibility from the beginning of the care journey. Increased interaction through brokers and other distribution channels can bring necessary empathy and compassion to patients during their illness.
In addition, insurance companies can play a key role in emphasizing preventive care. Many insurance companies in Hong Kong have implemented or are considering incorporating health and wellness plans into their policies. For example, some insurance companies have established strategic partnerships with third-party healthcare providers to provide one-stop cross-border medical services. This is exemplified by collaboration with various outpatient day surgery centers in Hong Kong. They speed up the patient’s surgical and treatment experience and reduce unnecessary costs, such as room and ward services. Patients can make various offline medical appointments through the insurance company’s mobile app, including health check-ups and diagnostics, to meet their needs at different life stages such as pre-marriage and pregnancy. The goal is to promote proactive health management through integrated partnerships and reward customers for healthier lifestyles. Leveraging integrated health data, such as electronic health records, claims history and health tracking wearables, along with rich population-wide data, enables customers to effectively monitor their health. Partnering with third-party health data platforms Analytics ensure timely understanding of emerging health trends, enabling customized services and personalized products.
The shift to an empathetic future
The integration of agent AI in health insurance claims management is not only a technological advancement but a fundamental shift toward a more empathetic, efficient and accurate claims process. By modernizing claims platforms and leveraging the capabilities of super agents and utility agents, insurers can significantly enhance the customer experience, reduce claims processing time and minimize errors. This shift is particularly important in the Asia-Pacific region, where dissatisfaction rates are particularly high and the need for a connected healthcare ecosystem is more urgent than ever. Insurers that adopt these innovations not only benefit in terms of financial performance, but also build long-term trust and loyalty with their policyholders. Additionally, an emphasis on preventive care and the seamless integration of online and offline healthcare services can lead to better health outcomes and lower healthcare costs for patients like Jane. As the healthcare landscape continues to evolve, insurance companies that prioritize these strategic changes will be better able to meet their customers’ needs and thrive in a competitive market. In our next blog we will provide a guide on how to Insurers can truly reap the full benefits of reinvention. In the meantime, if you would like to discuss how agent AI can play a role in your transformation journey, please contact us via the link below: Mark Xu or Sher Litan .
