Why Payers Must Consider AI Now to Tackle Rising Costs in 2024 and Beyond

The healthcare payer industry is navigating ongoing disruptions from economic pressures, workforce reductions, and Medicare Advantage restructuring. Mounting operational costs, tighter margins, and shifting regulations require swift adaptation in 2024. For example, Blue Shield of California recently laid off 61 employees in October, following 140 cuts earlier this year, while also ending its reliance on CVS Caremark and pivoting to a multi-partner model to reduce drug expenses by $500 million annually. 

This evolving landscape aligns with broader technological transformation, driven by new regulations like the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F),  aimed to streamline healthcare data exchange and refine prior authorization processes, impacting stakeholders across Medicare Advantage, Medicaid, CHIP, and marketplace insurers.

Additionally, Medicare Advantage plans are scaling back specialized services in response to inflationary pressures and regulatory changes, such as drug cost caps introduced by the Inflation Reduction Act. These challenges compel payers to re-evaluate investments in emerging technologies, particularly Artificial Intelligence (AI).

Despite concerns, AI offers low-risk, high-reward potential in non-clinical areas, like automating administrative workflows and streamlining operations. These tools can reduce costs, eliminate repetitive tasks, and enhance efficiency, helping payers stabilize operations and position themselves for sustainable growth in 2025 and beyond.

AI Is Not Just a Future Solution—It’s a NOW Solution

For today’s payers, efficiency isn’t just a goal—it’s the key to survival. Yet, challenges like manual processes, claims overutilization, delayed interventions, and fragmented care coordination are draining resources and shrinking margins.

These problems aren’t theoretical—they’re eroding profitability in real time.

The misconception that AI is too complex or requires years to deliver results holds many back. In reality, the right AI tools integrate seamlessly into existing systems, delivering fast, tangible wins.

Productive Edge’s AI Agent Accelerators are built to meet these urgent needs. Using Agentic AI, these solutions offer ready-to-deploy frameworks and workflows, helping payers automate tasks, reduce overhead, and streamline operations—achieving meaningful results from day one. With AI agents, you can stop waiting for ROI and start seeing impact now.

Why We Call Them Accelerators

Relying on future AI updates within your core platforms is a risk you don’t need to take. That’s why we designed our latest AI solutions as "accelerators"—built to make AI adoption seamless, fast, and efficient without waiting for broader platform innovations to catch up.

While many healthcare platforms are working toward adding AI features, those enhancements could be months or even years from full implementation, leaving critical workflows untouched in the meantime. Our accelerators bridge that gap, delivering immediate, targeted solutions to address your organization’s most pressing needs today—such as claims processing, addressing overutilization and managing prior authorizations, care coordination, and member engagement. And when your platforms do eventually integrate more AI, you’ll already be ahead of the game with a proven AI framework that complements and amplifies those innovations.

Here’s what makes our AI Accelerators different:

• Pre-defined Workflows: We’ve already built out the specific workflows and decision-making points AI can improve, so you don’t have to start from scratch.
• AI Agent Framework: Our accelerators leverage an AI Agent-based architecture that integrates directly into your existing systems—like Facets, QNXT, and others—so there’s no need for a complete system overhaul.
• Reference Architectures: We’ve partnered with leading cloud and AI platforms like AWS, Microsoft, and Google to create reference architectures that simplify deployment.
• ROI Calculators: You don’t have to guess at the financial impact. We’ve developed calculators that quantify potential savings and operational improvements upfront, helping you understand the ROI from day one.

In short, we’ve done the heavy lifting so that you can start seeing benefits faster—because we know time is of the essence.

Here’s What Our AI Agent Accelerators Can Do for You Today

Each of our AI Agent Accelerators is designed to solve today’s most pressing payer challenges. These accelerators can be rapidly integrated to deliver measurable outcomes in the areas that are costing you the most:

• Clinical: Reduce care costs by improving real-time decision-making. Automate critical tasks such as prioritizing high-risk members, coordinating care transitions, and predicting patient outcomes. This accelerator can immediately impact costs by reducing avoidable hospitalizations, shortening care plan development cycles, and improving care coordination across teams.
• Claims: Accelerate claims processing and reduce manual workloads by using AI to automate high-volume, repetitive tasks. This accelerator cuts processing times, reduces errors, and speeds up payment cycles, helping you see faster reimbursements and lower administrative overhead. You can avoid unnecessary payouts and reduce waste by improving fraud detection and claims accuracy.
• Prior Authorization: Enhance efficiency by automating the authorization process and proactively monitoring resource utilization. Using AI to flag inefficient resource use, you can streamline approvals, reduce administrative burden, and free up resources for higher-value activities. This directly reduces operational costs while improving service delivery times.
• Provider Support: AI agents enhance provider engagement by automating routine administrative tasks, reducing paperwork and saving providers valuable time while  minimizing friction, improving communication and collaboration.
• Member Services: Improve proactive member outreach and care engagement. Automate interactions based on member data and behavior, ensuring timely communications that improve health outcomes and boost member satisfaction. Personalized engagement strategies also reduce non-adherence costs, helping you mitigate unnecessary utilization of high-cost services.
• Customer Service: AI agents enhance healthcare customer support by automating routine inquiries, ensuring faster response times, and providing 24/7 assistance. They also alleviate clinical staff workloads, allowing care teams to focus on higher-value tasks, improving both patient satisfaction and operational efficiency.

Real Outcomes for 2025’s Real Problems

These accelerators aren't just about long-term digital transformation—they’re built to solve the urgent issues payers face today.

Here’s what you can expect in terms of immediate outcomes:

• Lower Medical Costs: Our AI solutions have been shown to reduce Medical Loss Ratios (MLRs) by 3-5%, which can lead to millions in annual savings.
• Operational Efficiency: AI automation frees up staff, reduces manual errors, and accelerates processing times, cutting administrative costs between 25% and 50%.
• Better Health Outcomes: With more personalized and proactive care strategies, readmissions can be reduced by 15-20%, directly contributing to healthier populations and reduced costs over time.

You Can’t Afford to Wait

With payers already under pressure in 2024—and challenges forecasted to grow in 2025—it’s clear: implementing AI into your strategy today is integral.

We get it—AI can feel risky, especially in healthcare. But here’s the good news: Our AI solutions aren’t involved in critical patient care decisions or authorization approvals. Instead, they target the operational side—automating workflows, enhancing efficiency, and eliminating manual tasks. The risk is low, but the rewards are high.

These solutions aren’t about adding complexity; they’re about streamlining what you already have to drive immediate cost savings. No need for a complete system overhaul. With easy integration, you can start where you are today and see measurable savings in just weeks, not years.

Ready to see AI agents in action? Get in touch with an expert today to see a personalized demo of our AI accelerators get insight into your savings opportunities.