AI/ML models provide valuable personalized recommendations: Pawan Sachdeva, Carelon Global Solutions India

Carelon Global Solutions, formerly Legato Health Technologies, was born out of one of the largest health plans in the US. This gives it a strong foundation, as well as agile flexibility of a startup.

Everything Carelon Global Solutions does is focused on transforming how healthcare works. Its digital platforms and tools make healthcare processes connected, integrated, and — most importantly — simple and seamless. To help customers operate at highest level, Carelon Global Solutions provides unparalleled information technology application support, data analytics, and business process services.

Pawan Sachdeva, MD, Technology, Carelon Global Solutions India, tells us more. Excerpts from an interview:

DQ: Can you give an overview on some key challenges that exist in the health insurance industry today?



Pawan Sachdeva: There has been a significant shift in the health insurance industry – and the healthcare industry as a whole – towards adoption of digital technologies and proactive, preventive measures, making connected and personalized healthcare the new norm. As these trends evolve, they create growing demand among healthcare payers and providers to adapt to the changing landscape.

By adopting a holistic and personalized approach to healthcare, organizations can better address the complex challenges withing healthcare as well as help each person improve their health and well-being. The industry has three opportunities in building a more resilient and efficient healthcare system.

Firstly, consumers are accustomed to proactive and predictive services in many aspects of their lives – retail, streaming services, etc. The healthcare industry has started making this shift to meet consumer demands and needs to continue providing services that are more proactive and personalized to both deliver healthcare services where, when, and how people want them as well as help people lead healthier lives.

Second is a growing demand for healthcare services and resources as the global population ages. Digital-first technology interventions and preventive care options can help deliver services at scale and in an efficient, cost-effective manner, while helping to ensure individuals receive the care they need.

With our growing reliance on technology, it's more important than ever to protect sensitive healthcare data. Healthcare providers, insurers, technology firms, and other stakeholders can work together to implement robust cybersecurity measures.

DQ: How is Carelon Global Solutions deploying advanced technologies like analytics, cloud, AI, and ML to address these challenges?

Pawan Sachdeva: As an organization supporting whole health, we are leveraging analytics and other exponential technologies to re-imagine healthcare. Our unwavering commitment lies in driving digital transformation and operational excellence for health insurers operating in the US.

Primarily, we have engineered robust APIs that facilitate seamless, real-time data exchange. This foundational infrastructure fosters integration of data across disparate systems, catalyzing process efficiency and operational agility.

At the heart of our technological prowess lies artificial intelligence (AI) and machine learning (ML). By analyzing vast amounts of data, our AI and ML models provide valuable insights and personalized recommendations, empowering insurers with the knowledge needed to make informed decisions and elevate the overall customer experience.

Furthermore, we utilize natural language processing (NLP) and robotic process automation (RPA) to help automate manual tasks – appropriately – and streamline workflows. This accelerates processes and enhances precision, particularly in areas such as claims processing. By automating appropriate transactions, we help enable insurers to be more efficient in claims settlement and help curtail operational expenses.

DQ: Can you elaborate on some solutions your organization has developed to enhance consumer experience?

Pawan Sachdeva: The consumer experience is more critical than ever in today's rapidly evolving healthcare landscape. Our organization is dedicated to transforming and optimizing every step of an individual’s healthcare journey. We understand that the journey begins with health plan enrollment, and we have developed a suite of innovative solutions to enhance this process and beyond.

Electronic Enrollment Gateway (EEG): Revolutionizing enrollment

Electronic Enrollment Gateway (EEG) is a game-changer in the healthcare industry. By harnessing the power of AI, we have eliminated the need for manual intervention in transferring paper enrollment forms into our system. This saves valuable time, enhances efficiency, making enrollment a breeze for members.

Digital Claims Examiner: Enhancing claims processing

When it comes to claims processing, our Digital Claims Examiner is truly remarkable. With the ability to handle over 3.5 million claims annually, this AI-based solution ensures accurate and timely processing. This translates into improved customer satisfaction as members experience seamless claims journeys.

AI-powered voice assistant: Personalized information at your fingertips

Our AI-powered voice assistant is designed to provide members with instant access to vital healthcare information and wellness insights. We empower members to conveniently access the information they need, making healthcare decisions easier and more informed.

Telehealth OS: Bridging the gap virtually

In a world where in-person healthcare visits can be challenging, our Telehealth OS connects members with healthcare professionals for virtual consultations. This platform offers convenient access to healthcare services, ensuring that members receive the care they need, when they need it.

Commitment to holistic solutions

As an organization, we strive to enhance the consumer experience, but we also promote seamless engagement with stakeholders such as employers and healthcare providers. Our comprehensive approach to healthcare ensures effective collaboration and improved outcomes for all. Our range of innovative solutions is dedicated to enhancing the consumer healthcare experience.

DQ: Elaborate how CGS has reduced manual efforts in health insurance through technology?

Pawan Sachdeva: Carelon Global Solutions has helped insurers to minimize manual processes by strategically incorporating technology. Our most noteworthy achievements lie in the domain of digital enrollment and claims adjudication. Our innovative solutions have led to a significant reduction in manual workload. This transformative shift not only simplifies the enrollment process, but also yields time savings for the insurers and their members.

We have harnessed automation to significantly enhance the efficiency of claims adjudication. Adjudication is an important step in a claims journey which defines the extent of coverage for claims. Efficiency in this process is integral for the insurer’s business growth. We deployed automation to this step and achieved an industry best auto adjudication rate.

By alleviating the burden of manual tasks in these pivotal areas, Carelon Global Solutions empowers insurance organizations to allocate their resources judiciously. This, in turn, grants them the latitude to delve deeper into their business operations, conduct rigorous growth projections, and make well-informed strategic decisions.

DQ: What is ‘Digital Nurse Assistant’, and how is it helping clinical examiners access critical information?

Pawan Sachdeva: In health insurance, timely decision-making is paramount, as it directly impacts individuals' lives. Clinical review and decision-making processes pose major hurdles in claims processing, which often results in delays in approvals. To tackle this issue and provide data-driven recommendations, we introduced the Digital Nurse Assistant. This solution leverages evidence-based insights to assist clinical examiners in efficiently accessing the information required for making informed decisions about authorization requests.

Through the utilization of advanced algorithms and data analytics, the Digital Nurse Assistant efficiently presents relevant and critical information to examiners, thereby enabling them to assess the legitimacy of requests and determine whether approval is warranted.

The Digital Nurse Assistant plays a vital role in improving clinical care operations by streamlining the decision-making process. By providing quick access to critical information and leveraging evidence-based insights, examiners can make more accurate and efficient decisions, thereby reducing unnecessary delays in claim approvals. This not only enhances the overall efficiency of the claims processing system but also elevates the experiences of healthcare providers and insurance members.

DQ: Can you elaborate on your partnerships with premier institutions, healthtech startups and accelerators, etc.?

Pawan Sachdeva: As a leading healthcare organization, we are dedicated to nurturing an innovation-centric, and learning-oriented culture for associates. Our strategic partnerships with premier institutions, such as IIT-Hyderabad, exemplify our commitment to providing our workforce with opportunities for leadership development and technical expertise through coaching and guidance from subject matter experts.

In our pursuit of cultivating a highly-skilled talent pool well-versed in modern technologies, we also acknowledge the dynamic startup ecosystem in India, which presents opportunities for specialized solutions. Our collaboration with T-Hub, a prominent startup incubator and accelerator, allows us to tap into this ecosystem, working closely with startups to leverage their innovative solutions and expertise to enrich our associates' experiences further and enhance our talent capabilities.

These strategic partnerships extend beyond enhancing our customer services; they are instrumental in enriching the associate experience for our 18,000+ associates in India. For instance, we have partnered with a startup to create a personalized associate engagement platform tailored to the unique needs of our associates in a hybrid work environment.

Remarkably, within just one year of implementation, over 12,000 associates are already benefiting from this platform, significantly boosting their engagement and productivity.

DQ: How are you nurturing your diverse talent pool in technology, and what kind of impact is your team creating from India?

Pawan Sachdeva: Carelon Global Solutions India is committed to nurturing its diverse talent pool in technology to make a lasting impact. We have recognized the importance of developing specialized skills in the healthcare industry, which is still emerging in India. To achieve this, we have strategically expanded our talent capabilities, assembling a unique pool comprising certified medical practitioners, data scientists, engineers, domain experts, and business professionals.

Continuous learning is a cornerstone of talent development within our organization. We have implemented initiatives to facilitate learning and growth, including strategic projects, partnerships, and a hub-and-spoke model through communities of practice and councils. These initiatives provide our talent with opportunities for experiential learning and on-the-job development, enabling them to evolve and thrive in their roles.

For career development and skill enhancement, we have launched digital platforms that enable associates to map their career paths and receive personalized recommendations for skill development. Our integrated learning portal equips associates with the tools to develop and measure their skills, aligning them with role requirements.

We leverage industry experts, both internally and externally, as well as academia, to mentor our top talent and facilitate accelerated learning and professional growth. Our commitment to talent development keeps us at the forefront of technological advancements, delivering exceptional solutions for clients and customers.