Reimagine the role of health claims with AI

<p><b>The health plans that win the next decade will be defined not by how well they process claims, but by how early they intervene intelligently in care collaboration.</b></p>

<p>The healthcare industry spends an <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC10986268/">estimated $200 billion</a> annually processing claims. But the more consequential problem is not the cost of processing; it is the timing. Most payer financial controls, clinical checks and integrity safeguards activate after care has been delivered. They’re reactive by design, recovery-oriented by default. The industry's dominant posture is pay-and-chase.</p> <p>Today, artificial intelligence gives health plan leaders an opportunity to fundamentally invert that model. By &quot;left-shifting&quot; validation, clinical review and financial controls upstream to the point of scheduling, pre-authorization and pre-submission, payers can move from reactive administration to proactive stewardship. The implications extend well beyond operational efficiency. Done at scale, left-shifting with AI is a direct lever on all three dimensions of the <a rel="noopener noreferrer" href="https://www.ihi.org/library/topics/triple-aim" target="_blank">Triple Aim</a>: better member experience, improved clinical outcomes and lower per capita cost.</p> <p>The question for executive leadership is whether your organization will lead this shift or respond to it.</p> <h4>From claims processor to care partner</h4> <p>Traditional payer operations are organized around a claims value chain including eligibility, prior authorization, coding, adjudication, appeals, payment integrity and remittance. Each step is handled sequentially, often by separate teams and systems. The result is a fragmented process that is expensive, slow to surface errors and largely invisible to members and providers until something goes wrong. This structure also creates further fragmentation of process and data.&nbsp;</p> <p>AI-driven left-shifting reorganizes this logic. Rather than validating claims after they are submitted, intelligent agents verify eligibility, flag care gaps, check clinical guidelines, validate payment integrity and surface billing issues before a claim is created. The claims process becomes a byproduct of better-informed care delivery, not a separate administrative burden layered on top of it.</p> <p>This reframing matters strategically. Payers that intervene early are no longer just administrators of financial transactions; they become active participants in care coordination, clinical decision support and network integrity. That repositioning has direct consequences for member loyalty, provider relationships and medical cost performance.</p> <h5>The Triple Aim case for intelligent intervention</h5> <p>There are myriad reasons to left-shift now, as explained here.</p> <ul> <li><b>Better member experience. </b>Members increasingly expect their health plan to function as a care partner, not merely a claims processor. Yet most payer-member interactions today are triggered by problems: a denied claim, a billing dispute, a coverage question that surfaces at the worst possible moment.<br> <br> Intervening early in the care lifecycle changes the interaction model. When AI agents verify eligibility and benefits at the time a member schedules an appointment, members arrive knowing their coverage, expected cost share and any required authorizations. When those same agents scan clinical histories to identify care gaps like a missed colonoscopy, an overdue A1C test or an unfilled specialist referral, providers can address them proactively during the visit. Members experience their plan as engaged and anticipatory rather than administrative and adversarial.<br> <br> This matters for retention. <a rel="noopener noreferrer" href="https://www.cognizant.com/en\_us/industries/documents/cognizant-voice-of-the-member-2026.pdf" target="_blank">Our latest Voice of the Member research</a> clearly indicates members think it’s important that their health plans actively support their well-being. Payers that deliver should see significantly higher member satisfaction and loyalty. Left-shifting creates the operational infrastructure to deliver on that expectation at scale.<br> <br> </li> <li><b>Improved clinical outcomes. </b>The clinical case for left-shifting may be the most underappreciated argument in the executive conversation about AI. Payers hold a uniquely comprehensive view of member health, including clinical histories spanning primary care, specialists, behavioral health, pharmacy and ancillary services. No individual provider has that visibility. AI agents that can synthesize this longitudinal picture and surface relevant clinical guidelines at the point of scheduling or pre-authorization have the potential to meaningfully improve care quality.<br> <br> Consider what becomes possible: prior to a member's appointment, an AI agent reviews their record and identifies that their diabetes management protocol is incomplete, that a recommended screening has lapsed or that a proposed treatment plan diverges from evidence-based guidelines. The provider receives this context before the visit. The payer does not have to chase a poor outcome after the fact. Care gaps close earlier. Chronic conditions are managed proactively. Adherence to clinical guidelines improves.<br> <br> This is not a theoretical benefit. Earlier identification of care gaps, combined with proactive condition management, reduces the incidence of high-acuity interventions that drive medical cost. Better outcomes are both the clinical and financial result.<br> <br> The cost reduction potential of left-shifting is substantial, and it operates through multiple mechanisms simultaneously.<br> <br> </li> <li><b>Administrative cost compression.</b> Flagging incorrect or incomplete claims before submission reduces payer intake gateway costs by up to 70%. Cleaner pre-adjudication claims translate directly into fewer pended claims, reduced appeals and grievances activity, less manual rework and higher auto-adjudication rates. Based on our calculations, payers can realistically expect a 25% reduction in claims processing costs within two to three years of deploying AI-driven left-shifting, with reductions of up to 40% achievable in four to five years.<br> <br> </li> <li><b>Medical cost avoidance.</b> When clinical guidelines are surfaced proactively and care gaps are closed earlier, unnecessary utilization declines. Preventive care and early disease management reduce the frequency of costly acute episodes. This is where the real margin opportunity lies—not just in administrative savings, but in bending the medical cost trend.<br> <br> </li> <li><b>Payment integrity, pre-adjudication.</b> Today, most payment integrity work happens after the fact. AI agents operating within clearinghouse workflows can check claims against contracts in seconds, catching improper unbundling, duplicate billing and coding errors before adjudication rather than after payment. This converts a recovery function into a prevention capability with compounding value over time.</li> </ul> <h5>Claims as a vehicle, not the destination</h5> <p>Operationally, the claims process remains the mechanism through which left-shifting is implemented. Three entry points offer the most immediate leverage:</p> <ul> <li><b>At appointment scheduling.</b> Agentic AI verifies eligibility, benefits and prior authorization requirements in real time, while simultaneously scanning member records for care gaps and relevant clinical guidelines. This single intervention point addresses member experience, clinical quality and downstream claims accuracy simultaneously.<br> <br> </li> <li><b>At pre-submission.</b> An intelligent layer between a provider's EHR and the payer's portal, delivered via API, can check a claim, verify eligibility and run claim edits before submission, returning a &quot;claim will be paid&quot; confirmation or flagging corrections. Providers who receive this signal earlier experience faster payment and fewer administrative follow-ups. Payers receive cleaner claims with fewer integrity issues.<br> <br> </li> <li><b>Through AI-enabled clearinghouses.</b> For payers operating with legacy IT infrastructure, an AI-equipped clearinghouse provides a practical path to left-shifted validation without requiring full system transformation. A dedicated AI agent can apply contract-aware claim checks at scale, converting post-adjudication payment integrity work into a pre-submission capability.</li> </ul> <h5>The executive action agenda</h5> <p>Left-shifting is not a single technology deployment. It is an operational transformation that requires reimagining processes and deliberate sequencing. With this in mind, here’s how leaders should get started.</p> <ul> <li><b>Automate high-volume manual processes first.</b> Start with agentic AI applied to current pain points like appeals and grievance triage, eligibility verification or claims fallout resolution. This generates near-term cost savings while exposing structural friction points that inform the broader transformation roadmap.<br> <br> </li> <li><b>Build the data foundation.</b> Left-shifting at scale requires a data engine, a platform designed to orchestrate information flows across sources and systems so the right data is available, governed and contextualized for AI agents at every decision point. Fragmented data is the most common barrier to realizing the full potential of agentic workflows. Addressing it is a prerequisite, not an afterthought.<br> <br> </li> <li><b>Reimagine processes, don’t just automate them.</b> The full value of left-shifting emerges when payers redesign workflows around AI capabilities rather than layering AI onto legacy processes. Prior authorizations can become automatic for standard requests when agents can verify all required data elements in real time. Care coordination becomes proactive when agents are scanning member histories during eligibility checks rather than waiting for a utilization trigger.</li> </ul> <h4>The competitive window is narrow</h4> <p>Several forces are converging to make left-shifting not just advantageous but necessary. For starters, the Centers for Medicare &amp; Medicaid Services has signaled its intent to move Medicare claims processing to a cloud-based platform capable of near real-time processing. Federal and state regulations continue to compress prior authorization timelines. Providers increasingly require payment certainty as a condition of network participation. And members, shaped by consumer experiences in other industries, expect transparency, speed and personalization that legacy payer operations cannot deliver.</p> <p>Payers that move now will be positioned to meet these expectations as the industry transitions toward real-time claims submission and settlement. Those that wait will find themselves retrofitting reactive architectures to meet real-time demands, a significantly more difficult and expensive path.</p> <p>The earliest movers will gain something beyond operational efficiency: a differentiated position as the kind of health plan that members and providers actively want to work with. Better experiences, better outcomes and stronger financial performance are not competing priorities when left-shifting is the strategy; they are mutually reinforcing results of the same structural change.</p>