Transforming Appeals and Grievances With Multimodal and Agentic AI

In part 1 of this series, we examined how autonomous artificial intelligence (AI) agents and multiagent workflows are enabling payers to revamp claims operations while reducing costs. In this installment, we explore another cost- and time-intensive function—appeals and grievances (A&G)—and how agentic AI, along with multimodal generative AI, can streamline that process.

Multimodal generative AI systems can interpret data across a wide range of media, including PDFs, image files, audio, video, computer code, and text. These systems can synthesize information from these sources while creating new content, such as summaries or letters. Adding these capabilities to an A&G workflow—augmented with AI agents working together—allows payers to improve the accuracy and speed of A&G, enhance quality and audit trails, meet regulatory deadlines, and increase member and provider satisfaction—all while reducing costs.

Agents and Multimodal Generative AI Working Together

A multimodal generative AI tool can read correspondence, summarize medical charts, review MRI results, CT scans, and X-rays, listen to phone calls, and generate activity timelines. It can use this information to classify and prioritize A&G cases by urgency and topic, acknowledge their receipt, and route them to the appropriate teams. In some cases, this may involve a virtual, agentic AI team. The agentic workflow can incorporate generative AI that consults the health plan’s policies, relevant medical criteria, and member benefits to make recommendations that expedite clinical decisions. Once a decision is made, the agentic workflow can generate responses, tailoring the complexity of the response to the audience and even translating it into a member’s preferred language.

Throughout the process, the multimodal AI and agentic AI workflow can create a detailed audit trail, documenting all the policies consulted and procedures followed. It can also generate the documentation required by an independent review organization.

Multiple Benefits From Multimedia-Enhanced A&G Processes

Agentic workflows enhanced with multimodal generative AI provide health plans with numerous benefits throughout the A&G process:

• Faster responses. Multimodal generative AI conducts reviews, generates summaries, and offers decision recommendations in seconds and minutes, rather than the hours and days typically associated with A&G cases.

• Reduced costs. This increased speed significantly reduces the cost and burden of A&G processes. Traditionally, A&G cases have been processed manually, which can easily incur costs of $43 to $118 per case when clinician and administrative time is considered. Costs are often much higher for complicated or escalated cases. AI-enhanced workflows can reduce these costs by an estimated 30% to 40%. For a midsized insurer with a membership of 1 million and an annual A&G volume of 700 000 per year, the savings could fall within $7.5 million to $10 million.

• Enhanced productivity. When AI tools manage tedious and routine tasks, such as acknowledgments and correspondence, it frees up time for A&G personnel and clinicians to apply their expertise and judgment to more complex cases.

• Reduced member and provider friction. A faster A&G process should aid member and provider relations. Quicker, accurate, and well-documented responses eliminate waiting and uncertainty. Health plans can combine these capabilities with care management strategies to support evidence-based alternatives, helping providers offer members effective treatements and improving outcomes.

• Continuous improvement. Making more consistent decisions, supported by solid documentation, enhances compliance and may reduce risk and legal exposure. Lessons learned from erroneous denials can be applied to minimize rework and optimize processes.

For example, a leading health plan operating across multiple states and business lines has automated the appeals process from various channels—including paper, eFax, contact centers, and online portals—into a unified case management system. The triage process is now largely automated with AI tools, and case creation and updates are handled seamlessly via application program interfaces (APIs). The copilot navigates through standard operating procedures and suggests the next best course of action. Documents and calls are efficiently managed, resulting in a significant increase in customer satisfaction, a 25% reduction in costs, and improved adherence to compliance standards, ensuring readiness for audits every day.

Putting Multimodal Generative AI to Work

It’s important to recognize that AI in the A&G workflow enhances the capabilities of experienced A&G personnel and clinicians conducting medical reviews. Multimodal AI can review and summarize data from a greater number of sources, equipping A&G specialists with the information they need to conduct thorough investigations and make informed decisions. Complex or nuanced cases will always require human oversight.

Enhancing A&G processes with multimodal and agentic AI is quickly becoming essential. Health care organizations that rely on manual workflows may find it increasingly challenging to contain costs as other organizations utilize AI to accelerate administrative processes. Proven AI solutions are on the rise, and health plans can collaborate with their service providers to test these with select providers to assess their value, then scale them. Far from being a novel technology, multimodal generative AI within agentic workflows will enable health plans to meet regulatory demands and enhance member and provider relations by swiftly addressing A&G cases.

About the Author

Deepan Vashi is the EVP & Head of Solutions for Health Plans and Healthcare Services at Firstsource with over 27 years of experience in health plan IT, business operations, and consulting. He is renowned for his expertise in developing member-centered digital solutions and building cross-functional teams to ensure successful implementation. In his role at Firstsource, he spearheads solutions and strategy for health plans, including Intelligent Back Office, Health Tech Services, and Platform-based Solutions (BPaaS). Deepan has extensive knowledge of innovative technologies such as Process Mining, Digital Twin, AI, and Blockchain.