We believe the Health insurance business is on the point of a major technology-driven disruption fueled by the rise of AI, digital business models, and a growing desire among all stakeholders to reclaim control of their healthcare expenditures. Payers’ operating model and their associated “services stack” can (and will) be unbundled by new out-of-industry market entrants with radically different margin structures and business models.
Employer-sponsored health plans have long been a profit sanctuary for Payers, but today we see the traditional underwriting business has, in large part, been replaced by lower-margin ASO offerings with the Payer being relegated to the role of a TPA. Furthermore, these TPA businesses are more vulnerable to competitive attack from a new breed of technologically advanced players. While the growth of Government lines of business has offset some of the compression in the commercial sector, these MCO businesses have low single-digit operating margins, are more competitive (with lower barriers to entry) and are inherently less predictable, being vulnerable to healthcare policy shifts at the state and federal levels. Payers are entering a new era of extreme margin compression where only the most efficient can survive.
Machinify set out to help Payers fundamentally re-tool their operations and develop a new portfolio of AI-enabled digital services and processes to counter the emerging competitive threats. We have successfully demonstrated the transformative impact of an AI-first approach to core operations, from claims processing to utilization management.
Our full-stack AI-powered Payment Integrity solutions, has been applied to almost every aspect of claims adjudication with dramatic results relative to the traditional rules-driven, labor-intensive status quo. From coordination of benefits to subrogation, medical bill and chart audits to claims edits and detecting FWA, real-time AI-assisted decisioning has proven to be a game-changer for process efficiency and quality. Machinify can be deployed “upstream”, as the core and enabling technology to support Provider RCM functions, as well as in the support of Payers focused on end-to-end, Pre and Post-pay Payment Integrity processes.
Machinify provides software that integrates seamlessly into existing IT infrastructure and enables a gradual transition of more and more decision-making from rule engines and heuristics to an AI-led process with built-in feedback loops for continuous refinement. Machinify solutions can also be deployed as a standalone platform to augment and support existing Payment Integrity teams. We focused our early efforts on the Healthcare payments market because we believe claims adjudication and payment processing represents the central nervous system of every Payer operation and must remain a core competency. But Machinify’s growing portfolio of AI offerings can support and transform almost every aspect of a Payer’s operating model.