Oscar Program Structure

05: Managing Care

How we put guardrails around care delivery through authorizations and active management.

3 AI use cases

Manage Utilization

Choose which care is appropriate, through prior authorization and active case management.

Prior Authorization

Authorize surgeries, drugs and specialty referrals.

  • Status: Pilot / Prototype

    While the healthcare industry has made strides to digitize in some areas, a lot of information still flows via fax and the exchange of paper. A prime example is the authorization forms submitted by doctors to get approval for complex or high cost procedures. We’ve seen that AI can play a role in extracting relevant details from unstructured information sources such as these, to speed up processing times.

  • Status: Launched / Coming soon

    Health plans define a set of policies that govern which types of care are covered under what circumstances, a process that is highly regulated for good reason. In particular, when providers request approval for procedures that require a prior authorization, a series of review steps ensues including by medical professionals. Some of these tasks are purely administrative and this is where AI can play a significant role, ensuring that reviews are processed in a timely way, and freeing up clinical team members for clinical judgment-based responsibilities.

Case Management

Manage members in important clinical moments, such as discharge planning, transplants or other complex cases.

  • Status: Pilot / Prototype

    Oscar, like many health plans, has a set of programs geared toward helping members with chronic conditions. But one of the challenges most payors have is identifying whom to enroll in these programs and then of course educating members about them. This first of these problems is now much more easily solvable, and we’ve tested it out as one of many use cases for a new set of AI actions in Campaign Builder.

Manage Feedback

Manage feedback from our members and providers.

Manage Provider Disputes

Provider disputes often deal with complex payment or authorization disagreements.

Drive Up Satisfaction Rates

Monitor net promoter scores for members, providers and brokers, and encourage them to talk about their experience with our products.

Field Member Grievances and Appeals

Grievances and appeals are a highly regulated form of member feedback that requires fast resolution and documentation.