AI has become an invaluable tool in combating fraudulent claims in the health insurance space: Brij Sharma, Founder and Chairman, MDIndia

Brij Sharma, Founder and Chairman, MDIndia, a leading health insurance TPA in India, shares insights on how his company is revolutionizing the sector with AI, improving everything from claims processing to personalized health solutions

Some edited excerpts:

How is AI currently being integrated into your operations, and what specific areas of health insurance impact the most?
At MDIndia, AI integration is a strategic priority as it transforms how we operate across various functions. We are leveraging AI in claims adjudication, fraud detection, customer service, and data analytics. By automating repetitive tasks, such as verifying claim documents and policy terms, AI frees up our workforce to focus on higher-value activities like decision-making and complex case evaluations.

Additionally, AI is enhancing our ability to deliver personalized health solutions by analyzing vast datasets, including claims histories and medical records. This has led to more accurate risk assessments and tailored offerings for corporate clients and individuals alike. The impact is most visible in claims processing, where AI ensures quicker resolution, and in fraud detection, where it identifies anomalies with remarkable accuracy.

Can you explain how AI technologies are improving the efficiency and accuracy of claims processing? Are there any specific case studies that illustrate these benefits?
AI has revolutionized claims processing by introducing speed, precision, and consistency. By using natural language processing (NLP) and machine learning algorithms, we automate the evaluation of claim submissions, cross-referencing them against policy terms, medical codes, and historical data. This minimizes manual errors and ensures claims are processed promptly.

For instance, in a high-volume corporate account with over 10,000 employees, we deployed an AI-powered system to audit and adjudicate claims. The system not only reduced the average processing time by 40% but also identified discrepancies in 5% of claims, saving significant costs. Such efficiency improvements have been instrumental in strengthening our service delivery and client satisfaction.

How does AI help in identifying and preventing fraudulent claims?
Fraudulent claims are a significant challenge in the health insurance industry, and AI has become an invaluable tool in combating this issue. Our systems leverage machine learning and predictive analytics to analyze patterns in claims data. Algorithms are trained to identify irregularities, such as inflated medical bills, duplicate claims, or treatments inconsistent with the diagnosis.

For example, we recently detected a pattern where multiple claims were submitted under different names but traced back to the same individual. The AI flagged these anomalies instantly, allowing us to investigate and prevent substantial financial loss. By incorporating technologies like anomaly detection models and network analytics, we’ve seen a 30% reduction in fraudulent payouts over the past year.

In what ways does AI enhance the security of sensitive patient data and ensure compliance with regulations like HIPAA?

Data security is paramount in healthcare, and AI helps us stay ahead of potential breaches. Our systems use AI-driven encryption and real-time monitoring to detect unusual access patterns or unauthorized activities. Additionally, we employ AI to manage compliance with HIPAA and other regulations by continuously scanning our operations for any vulnerabilities.

For instance, AI-powered tools monitor how sensitive data is accessed and shared within our ecosystem. Any deviations from standard protocols trigger alerts, allowing us to act swiftly. This proactive approach not only ensures compliance but also builds trust with policyholders by safeguarding their private information.

How is AI enabling personalized insurance plans and healthcare services for policyholders? Can you provide examples of data-driven insights used in this process?
Personalization is a key driver of value in health insurance, and AI enables us to deliver it effectively. By analyzing data such as medical history, claims patterns, and lifestyle factors, we can design tailored insurance plans that address the unique needs of individuals and corporate clients.

For example, for one of our large corporate clients, AI analyzed employee health data to recommend preventive health packages focused on specific risks like diabetes and hypertension. This resulted in a 25% reduction in hospitalization claims within a year. Such initiatives not only reduce costs for insurers but also promote better health outcomes for policyholders.

How do you utilize AI for predictive analytics in health insurance? What trends or patterns are you able to identify that benefit both the insurer and the insured?
Predictive analytics allows us to anticipate trends and make informed decisions. Using AI, we analyze large datasets to predict claim probabilities, identify high-risk groups, and forecast health trends. For instance, by studying claim histories and demographic data, AI helps us identify patterns such as seasonal surges in certain illnesses or the likelihood of chronic conditions in specific groups.
This insight allows us to proactively design interventions like wellness programs or tailored insurance products. For insurers, it reduces claim ratios, while policyholders benefit from targeted health services that improve their quality of life.

In what ways has AI improved operational efficiency within your organization? Are there metrics that demonstrate this improvement?
AI has streamlined our operations across the board. From automating routine processes to optimizing resource allocation, the efficiency gains have been significant. For example, our AI-powered document verification system processes claim documentation 50% faster than manual methods, reducing the average turnaround time for claims by 3 days.

Moreover, AI-driven customer support tools like chatbots have handled over 70% of customer queries without human intervention, freeing up our team to focus on complex issues. These improvements have led to a 20% increase in overall productivity and enhanced customer satisfaction scores.

How does AI facilitate better patient engagement and communication in the health insurance process?
AI enables us to maintain continuous and meaningful communication with policyholders. Tools like AI-driven chatbots and virtual assistants provide real-time support, guiding users through claim submissions, policy renewals, and even preventive care reminders.
For instance, policyholders receive personalized health tips and alerts for routine check-ups based on their health profiles. This not only improves engagement but also fosters a sense of care and commitment from our organization, strengthening long-term relationships.

What do you see as the next big trends in AI for the health insurance sector? How are you preparing to adapt to these changes?
The next wave of AI in health insurance will focus on real-time data analytics, AI-driven telemedicine, and precision health interventions. Additionally, natural language processing (NLP) will further enhance customer interactions, making insurance processes even more intuitive.

At MDIndia, we are preparing for these trends by investing in scalable AI platforms, collaborating with technology partners, and upskilling our teams. By staying at the forefront of innovation, we aim to deliver solutions that are not only efficient but also deeply customer-centric.

What challenges do you face in implementing AI solutions, and how are you addressing them?
The challenges in AI implementation primarily involve data standardization, system interoperability, and workforce adaptation. Ensuring high-quality, consistent data is critical for AI to function effectively. We are addressing this by streamlining data collection and management processes.

Another challenge is integrating AI tools with existing legacy systems, which requires careful planning and robust IT infrastructure. Lastly, we recognize the importance of upskilling our workforce, so we have initiated training programs to help employees adapt to AI-enabled workflows. These steps ensure that we overcome hurdles while maximizing the benefits of AI.