The insurance industry has long been viewed as complex and intimidating, especially when it comes to understanding what is covered and what isn’t—particularly in health insurance. With the rise of artificial intelligence (AI), companies like Anomaly are pioneering solutions that simplify, clarify, and revolutionize how both providers and policyholders navigate insurance coverage. In this article, we’ll explore how AI is being used in the insurance industry, focusing on transparency, certainty, and real-world applications you can benefit from today.
The Challenge: Complexity and Lack of Transparency in Insurance
Why Insurance Is So Difficult to Navigate
- Insurance policies are often written in dense, free-text contracts with ambiguous language.
- Consumers face difficulty deciphering what is actually covered before receiving care.
- Uncertainty leads to frustration, denials, and unexpected costs after treatment.
“It shouldn’t be as difficult to unpack as requiring AI to do it. But it turns out it is.” — Mike Desjadon, CEO of Anomaly
The Real Impact on Policyholders
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- 83% of Americans, according to the American Hospital Association, want more transparency from their health insurance.
- Even industry insiders struggle: Mike Desjadon describes challenges he faced with his own coverage despite leading a company focused on solving these very problems.
How AI Solves Insurance Transparency and Certainty
Decoding Insurance Policies with AI
AI is leveraged to “decode and unmask” what insurance will cover, addressing three core objectives:
- Clarity: AI parses complex contracts and policies to present clear coverage information.
- Certainty: Policyholders get upfront information about what is likely to be paid or denied.
- Efficiency: Technology streamlines processes that would otherwise be daunting and manual.
Key Benefits for Consumers
- Reduce intimidation: AI breaks down jargon, making insurance more approachable.
- Know before you go: Understand what’s covered before receiving care, not after.
- Avoid surprise bills: Proactively identify potential denials and out-of-pocket costs.
How AI Works in Insurance: Data and Learning
The Data Behind AI Decisions
AI systems in insurance are trained on two main data sources:
- Health bills/claims: Data from providers about services rendered.
- Remittances (remits): Insurer responses indicating what was paid or denied.
Machine Learning Models in Action
- Large language models and machine learning parse contracts, policies, and historical claims.
- AI identifies patterns in what’s actually covered vs. written policy terms.
- Gaps and inconsistencies are flagged to inform doctors and patients in advance.
Example: Predicting Denials and Approvals
- AI reviews past claims and insurer payouts.
- The model learns common reasons for denials.
- When a new claim is prepared, AI predicts the likelihood of approval or denial.
- Providers can inform patients before care is rendered, reducing surprises.
Real-World Impact: AI Applications in Health Insurance
Empowering Doctors and Patients
- Doctors can advise patients in advance about coverage likelihood.
- Patients gain peace of mind with clear, upfront information about potential costs.
Supporting Policymakers and Industry Change
- AI-driven insights help policymakers push for greater transparency.
- Insurance companies can use AI to streamline operations and reduce manual errors.
Success Stories and Industry Adoption
- Companies like Anomaly are actively implementing these models in real-world healthcare settings.
- Early results show reduced denied claims and greater satisfaction among both doctors and patients.
Actionable Tips: How Consumers Can Benefit from AI in Insurance
1. Ask Your Provider About AI Tools
- Inquire if your healthcare provider uses AI-powered platforms to predict coverage.
2. Use Digital Portals and Transparency Tools
- Many insurers now offer online tools that use AI to show likely coverage before you receive care.
3. Stay Informed About Your Rights
- Leverage state and federal transparency initiatives that require insurers to disclose coverage details.
4. Review Claims and Remits Proactively
- Check explanations of benefits (EOBs) and remittance advice for clarity—and challenge denials if needed.
Key Takeaways and Looking Ahead
AI is reshaping the insurance industry by making it more transparent, predictable, and user-friendly. By leveraging claims data and machine learning, companies like Anomaly are enabling both patients and providers to know what’s covered before care is given, reducing surprises and eliminating a key pain point of the healthcare experience. The future of insurance is smarter, clearer, and more certain—thanks to AI.
“We can use technology now to make that much better on the front end.” — Mike Desjadon
Ready to Take Control of Your Insurance Experience?
Explore whether your provider offers AI-powered transparency tools. Stay informed, ask questions, and take advantage of new technologies designed to put you in control of your coverage. For more insights on the future of AI in insurance, subscribe to our newsletter or check out related articles on AI in Healthcare and Insurance Technology Trends.
