Revolutionizing health plans’ clinical review process with GenAI
Our client, a regional health plan, partnered with HCLTech to reimagine their clinical review operations. With an unprecedented surge in appeal volumes and increasing regulatory pressures, they needed a solution to reduce clinical review turnaround time and the administrative burden while maintaining quality and compliance.
HCLTech delivered a GenAI-powered platform that streamlined the end-to-end clinical review process, freed up the clinical staff for more complex cases, improved operational efficiency and enhanced member and provider satisfaction.
The Challenge
Strain in the clinical review process from a surge in appeals and complex documentation
The client faced a rapid increase in appeal volumes and complexity in medical documentation. Manual review processes led to delays, inconsistency and clinician fatigue, putting the organization at risk of compliance gaps and operational inefficiencies.
Several specific issues further compounded these challenges:
- The clinical review team experienced a 125% increase in appeal volume year-over-year, reviewing 1,285 inpatient appeals in 2024
- Clinical reviewers spent 2–3 hours reviewing each case due to inconsistent documentation, complexity of benefit plans, eligibility records and volume of medical histories
- Staffing shortages and regulatory timeframes intensified operational strain
- Implementing standardized processes across multiple clinical reviewers proved to be challenging
The Objective
Streamline clinical reviews with GenAI-led automation to enhance efficiency
Our client sought to streamline its manual clinical review workflows by introducing generative GenAI-led automation, complemented by human intelligence. This approach was intended to reduce the rising workload and enhance the efficiency and accuracy of appeals.
The client aimed to:
- Accelerate review processing for appeals, grievances, prior authorizations and claims
- Maintain high decision quality
- Create a scalable solution aligned with regulatory compliance and plan-specific guidelines
- Ease member anxiety with expedited resolution
- Enable more transparent communication with provider partners
The Solution
GenAI-powered solution streamline clinical reviews with intelligent automation and compliance
HCLTech developed and implemented a GenAI-powered clinical review solution designed to support intelligent document summarization, contextual decision support and embedded compliance validation, without compromising clinical oversight.
Our solution included:
- Smart summarization: Automatically extracting relevant information from lengthy documents, including benefit plans and clinical records.
- AI-powered decision support: Provided automated recommendations on approvals or denials with a confidence score, enabling rapid yet safe decision-making, in compliance with CMS, NCQA and plan-specific guidelines.
- Seamless integration: The system was designed to support seamless integration with the existing clinical review workflow.
- Secure processing of medical records: Processed patient medical records in PDF format and safely handled sensitive information.
- User-friendly interface: Provided an intuitive, user-friendly interface that displayed results clearly and allowed easy queries to get prompt responses.
- Cost-effective AI model management: The AI model costs were effectively managed during the proof of value (POV) phase, ensuring the project remained financially viable.
- Built on hyperscalers: Deployed using Azure OpenAI (GPT 4) by leveraging Azure’s machine learning studio, storage and search services.
- Rapid implementation: Built to support rapid implementations ranging from 4-6 weeks.
- Responsible AI principles: The guardrails were maintained to firm up the ethical considerations and eliminate any model hallucinations. Data access and usage were appropriately protected through Azure Cloud’s reliable infrastructure and secure data storage, which supports HIPAA compliance and ensures security and privacy controls and processes.
The Impact
Enhanced clinical review process with streamlined reviews, efficiency gains and clinical satisfaction
The solution with scalable clinical intelligence delivered measurable improvements with the end users reporting dramatic efficiency gains, with time spent on initial reviews being reduced to as little as 15-20 minutes to complete a case review and make consistent decisions. Clinical reviewers could focus on high-value activities while AI managed repetitive data processing tasks.
The results were transformative:
- End users reported a reduced time spent on initial reviews by 85%, decreasing from an average of 2-3 hours to just 15-20 minutes per case review
- The streamlined review process enabled more consistent and reliable decision-making
- The solution addressed rising administrative waste and lowered operational costs by 75% through increased automation and enhanced process efficiency
This transformation showcases the power of combining clinical expertise with responsible AI to address growing operational challenges. By streamlining complex workflows and reducing manual effort, the solution enabled faster, more consistent decisions while improving clinician satisfaction and compliance. It sets a strong foundation for scalable, intelligent healthcare operations that are both efficient and patient focused.
