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  4. AI is the answer to innovation in the claims process

AI is the answer to innovation in the claims process

Publishing Details

General Insurance

29 Jul 2022
Niels Thone
Joanne Richardson
Featured in ITIJ 259 | August 2022

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AI and claims

In a recent webinar, Niels Thoné, Co-Founder and Chief Growth Officer (CGO) of Sprout.ai (Sprout), and Joanne Richardson, former Health Director at AXA, sat down to discuss the challenges in the market today, and how AI can be used to overcome these in a results-led approach

There were two main takeaways for listeners: that health insurance providers want the claims process to be just as painless as customers do, and that tech solutions are key to bringing these processes up to date and making them easier for customers, medical providers and insurers.

Common goals and ongoing hurdles

It’s clear that customers, providers, and shareholders have a common objective: all desire the best outcome in the most accurate and efficient way possible. However, at a time when customers are at their most vulnerable, they have to face a process that is notorious for being clunky, outdated, and prone to errors and fraud, waste and abuse (FWA). Whilst simple claims may be processed very quickly, a more complex one can take up to 25 days or more to process.
Innovation is clearly a priority for the insurance industry, both in improving standards of customer service and also in providing access to digital services, such as symptom checkers and prevention of authorised push payments (APPs). However, addressing the issues with claims is often seen to be too expensive and complicated due to the age and bespoke nature of many existing health claims systems.

Increasing costs impact health insurance

Following the global pandemic, people are increasingly turning to private insurance as they realise how long the waiting lists for treatment in the state system are becoming. Now, it’s up to insurance companies to react accordingly. However, the current global crisis is fuelling inflation. This puts pressure on claims costs, which is reflected in increasing prices. What’s more, it’s not yet clear how high medical inflation will go. Regardless, it’s clear that there’s no time to waste by waiting to see what these effects will be; this approach risks losing customers as cover becomes less affordable, or profits are reduced in what is already a low-margin business. Insurers must find ways to reduce costs in the short term, whilst improving the processes themselves in order to make the most of the opportunity that the pandemic has presented.

Solutions through technology

This is where groundbreaking solutions come in. According to Niels, Sprout’s ultimate goal is 'to provide a frictionless insurance claim experience for everyone in the world'. Through a unique multi-modality use of computer vision, machine learning (ML) and natural language processing (NLP), the Sprout team have developed an AI program that can be easily implemented by top insurers.
A key reason that the claims process is so clunky is due to the sheer amount of unstructured data involved with one claim – the claims team has to sift through pages of handwritten notes and memos to process a single claim. It’s no wonder, therefore, that this can take up to 25 days. With technology, this can be reduced to three, at an accuracy rate of 96 per cent (which is three per cent greater than the human eye).
Through a combination of computer vision, ML and NLP, software programmes can extract claims data before structuring, understanding, and triaging it in a cohesive way, all whilst checking for fraud to avoid FWA. With these solutions, insurance companies can significantly improve the experiences of their customers without changing or replacing their existing claims systems and data structures. This, on top of the superhuman levels of accuracy, is what makes such solutions so attractive to insurance companies, and why there is no excuse for being slow on the uptake of innovation from legacy systems. 

ITIJ August 2022

This article originally appeared in

ITIJ 259 | August 2022

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Publishing Details

General Insurance

29 Jul 2022

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Niels Thone

Niels Thone is the co-founder and CEO of Sprout.ai, an insurtech startup that uses AI to reduce the number of fraudulent claims, improve efficiency and reduce costs for insurers, while aiming to improve customers' claim experience. Sprout’s clients include some of the largest insurance companies worldwide, such as Zurich International. 

Joanne Richardson

Joanne Richardson has over 20 years of experience working in health insurance across multiple countries for AXA, including Mexico, France and the UK. Before retiring last year, Jo worked for five years as a Health Director in the Group head office in Paris, developing group strategic initiatives such as Care Coordination and then working in Group Risk Management leading in-depth reviews of the major AXA health entities, helping ensure long term profitable growth through International best practice.

Neils Thone - Co-founder and Chief Growth Officer

Joanna Richardson - Former Health Director at AXA
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