Squeezed for capital and new sources of value in a competitive and challenging market, US health insurers can turn to artificial intelligence (AI) solutions to unlock billions of dollars in value. While AI can be a vehicle to achieve change, it is a much more complex and dynamic innovation with the potential to evolve beyond expectations. Possessing a survival guide may help payers make their organizations more intelligent by developing a sustainable strategy, targeting specific capabilities to drive near-term value and shaping a program for long-term success.



The value conundrum

New customer demands and impending market disruption are placing a squeeze on US health insurers for capital necessary to navigate imminent industry change. The tap of free-flowing capital has long run dry and traditional sources of unlocking new value are plateauing. How can US health insurers quickly generate new value for their enterprise to navigate a strategic course to “the new”?

According to Accenture analysis, US health insurers can unlock up to $7 billion in total value in 18 months, using solutions driven by artificial intelligence (AI). This value could be generated primarily from six different capability areas that align to an insurer’s operating model (see Figure 1). For an individual health plan, it equates to unlocking $1.5 million in operating income for every 100 full-time employees (FTEs), by the end of the next calendar year, as a result of automating core administrative functions using AI.

Starting at the core

Starting on core administrative functions allows health insurers to not only modernize processes, but also develop a data-driven foundation that enables the enterprise to realize the significant long-term potential of improving clinical outcomes.

This approach can also provide leadership with the right tools to embark on a course that confirms tangible value can be realized:

Viability, today.

A sizable portion of in-market solutions are tried and tested, across industries, removing uncertainties associated with the technology and implementation.

Real value, tomorrow.

Solutions can maximize resource productivity, enabling the redirection of FTEs to high-value functions and alleviating future need for additional FTEs while implementing lower-cost technologies.

Testbed, for the future.

Revisiting the enterprise’s data structure and models could better tie a health insurer’s administrative responsibility to enabling clinical innovation to improve healthcare, unlocking further value.

Targeting near-term value

Technologies such as robotic process automation (RPA), intelligent automation, virtual agents and machine learning can be incredibly transformative, freeing up resource capacity to redeploy toward more strategic functions under a potentially self-funding model.

According to Accenture analysis, the top three areas for health insurers to start, for near-term value in the next 18 months, are:

Anticipating and resolving customer questions.

Improving the benefits loading process.

Accelerating prior authorization & clinical claims review.

Where to (re)invest

To protect incumbency, payers can reinvest savings from automating the core in more advanced capabilities aimed at leapfrogging the competition. According to Accenture research, the top three capabilities that drive Net Promoter Score (NPS)1 lie in evaluating insurance, buying insurance and resolving administrative functions2.



Payers can invest in technologies to provide a richer shopping and support experience to members to increase retention and loyalty. Those that can continuously automate their core operations and fuel investment in more strategic priorities will win the consumer in this new payer world.

AI, however, is a much more complex and dynamic innovation with the potential to evolve beyond expectations. To thrive, health plans must identify the right solutions, partner with the right vendors, define the appropriate governance structure to manage a sustainable and profitable program, and outline a road map for implementation.

1 Net Promoter, Net Promoter System, Net Promoter Score, NPS and the NPS-related emoticons are registered trademarks of Bain & Company, Inc., Fred Reichheld and Satmetrix Systems, Inc.

2 Accenture 2017 Customer Experience Payer Benchmark Survey.

Richard Birhanzel

Managing Director, Payer Practice – Accenture Health


Richard Fu

Manager – Accenture Strategy


Joshua Kraus

Business Strategy Manager

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