The First Stage of an “Enterprise AI Transformation” Approach

June 14, 2023

We have defined this first stage as “Alignment & Discovery” where we seek answers to questions that help us assess a healthcare organization’s current use of AI and AI adoption readiness. Depending on the project, there will be a set of solution specific questions about applying AI. For example, if you are a health plan considering a business area that is not automated, under-automated, or needs to be redesigned, we tailor our discovery to define the scope and level of effort to complete the transformation project with AI as a component of the technology architecture, or as the primary technology driving the process design/redesign. 

Let’s consider use cases that require a thorough understanding of a shared-risk provider contract with an IPA from the health plan’s perspective. These use cases require identifying and assessing how relevant provider contract provisions impact the business process addressed in the use case. Initially, driven by the use case requirements, AI would be used to identify and assess the provider contract terms and conditions – a manually performed activity today completed by experienced workers familiar with provider contracts. Use cases could range from AI-driven referral/authorization automation/utilization management, AI-assisted determination of division of financial responsibility (DOFR), AI-driven capitation payment processing/reconciliation, or AI-recommended configuration steps for updating the health plan’s rate tables and rules for claims adjudication once DOFR is completed. 

To gain insight into how the health plan is currently utilizing AI and get a sense of the organization’s AI adoption readiness, we ask a range of business and IT-related questions, including: 

1) How are you currently utilizing AI if at all? 

2) How do your current third-party vendor products around provider contract management incorporate or utilize AI, if at all, and how and what type of AI have been added to the products you have implemented? 
3) Are you planning to roll-out the AI solution across the enterprise or is this a phased implementation by plan or region? 

4) What are the quantifiable benefits to be realized for the use case and/or “solution”? 

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