How artificial intelligence is helping healthcare payers work smarter

Artificial intelligence (AI) is becoming an increasingly important part of health plan operations. In Prime Therapeutics' (Prime's) recent survey of 57 health plans representing 246 million covered lives, 70% reported using AI tools in their daily work.

For payers, the benefits of AI extend beyond automating routine tasks. AI can bring information together and uncover useful patterns, giving experts more time to make decisions that improve care, affordability and patient experience. But the value AI creates ultimately depends on the goals and incentives guiding its use.

At Prime, AI is designed to help clients make decisions around patient needs, clinical appropriateness and total cost of care - not to maximize the value of individual transactions or favor owned businesses.

"The question for payers is where AI belongs in healthcare, and what outcomes it is designed to advance," said Greg Myers, vice president of AI strategy at Prime. "The best uses of AI reduce the administrative work, give patients greater clarity and help experts make decisions based on clinical value, affordability and the patient's broader care journey while keeping humans in the loop and accountable for decisions about care."

Here are three ways AI can help strengthen payer capabilities and improve care, manage costs and create a better patient experience.

1. AI is reducing administrative burden. AI can reduce administrative burden by summarizing information, supporting research and assisting with routine communications, scheduling and documentation. Prime is strengthening that foundation by standardizing the intake of clinical information, referrals and supporting documentation, helping ensure consistent, accurate information, supporting more predictable case progression and preparing workflows for future AI capabilities. The goal is to reduce avoidable friction so clinical and operational teams can spend more time helping patients access appropriate care and supporting the priorities of the health plans and employers they serve.
2. AI is strengthening decision support. AI can help providers, pharmacists and care teams make more informed decisions by bringing clinical, pharmacy, operational and cost information together. Predictive models can identify unusual patterns and help teams focus attention where it may be needed most. The advantage is not simply having more data; it is connecting information across the patient's care journey so experts can see tradeoffs and act with a more complete picture. When designed around aligned incentives, AI can support decisions that consider a patient's full care journey and total cost of care rather than focusing on a single claim, benefit, service or owned asset. AI helps surface insights, but experienced professionals make the final decisions based on member needs and overall value.
3. AI is creating more responsive experiences. Chat-based support and personalized guidance can make benefits easier to understand and routine steps easier to complete. When these tools are designed around shared goals for access, affordability and outcomes, they can offer guidance based on the patient's needs and the client's priorities, not on a predetermined pharmacy, channel or business asset. Human support remains essential for sensitive, unusual or clinically complex situations.

Trust must grow with adoption

As these capabilities expand, trust must grow with them. A 2026 Coalition for Health AI survey found that 75% of respondents use AI, but only 13% feel very comfortable with it. More than 80% said clear accountability would increase their trust.

Prime's differentiated model, which aligns incentives to patient value, allows the organization to build trust by using AI to strengthen human judgment and support better decisions rather than to replace human expertise. Clear accountability, strong privacy and security protections, regular checks for accuracy and bias, and human review help ensure AI is used safely and responsibly. By showing clients how AI reaches its conclusions, Prime gives them greater clarity and confidence in using it.

What payers should prioritize

To move from isolated use cases to lasting value, payers should focus on four practical priorities that keep technology, partners and decisions aligned around better outcomes and affordability:

• Start with the problem. Focus on work where AI can reduce friction or improve decisions.
• Design for the workflow. Define how AI fits a process and where human review occurs.
• Measure and govern. Track quality, experience and outcomes while monitoring data, performance and accountability.
• Build with aligned partners. Health plans, pharmacy benefit managers, providers, manufacturers and technology companies each hold part of the patient journey. Shared goals and clear responsibilities help them use AI to improve care, affordability and member value together.

The next step is to move from promising AI pilots to solutions that deliver meaningful results. Technology alone will not determine which solutions succeed; the incentives, data and human expertise surrounding it will. Prime's aligned model, connected view of medical and pharmacy care, and human clinical expertise help clients use AI to improve care, lower costs and create a simpler member experience together.