Healthcare / Medical Insurance
Within the healthcare and medical insurance sector decisions to fund care and pay or repudiate claims are highly consequential. Inappropriate decisions may be life threatening, lead to complaints which may escalate to lawsuits, while excessively lenient decisions place undue pressure on already constrained healthcare systems and unnecessarily erode funds.
Despite great strides in automation and prediction technologies medical schemes and healthcare providers continue to rely on the knowledge and expertise of clinicians, claims and even forensic experts to make appropriate decisions on their behalf.
While human expertise is necessary to navigate risk and uncertainty, the challenge is two-fold:
human capacity is constrained - this leads to delays in processing
human expert opinion on the most appropriate action may differ - this leads to inconsistent decisions across the system
The Solution: TOM™
Merlynn’s next generation AI, the Tacit Object Modeler TOM™ digitally replicates human expertise to create a Virtual Expert - a digital replica of the decisions made by the organizations top experts. Digitized expertise provides more consistent decisions. A panel of digital experts enhances decision accuracy. The panel of Virtual Experts are able to simultaneously, in real-time, provide input & expertise on the most appropriate course of action for patient care enabling healthcare providers and insurers to better manage risk.