According a recently released Bain and KLAS report, both providers and payers are focusing on the AI investments “most likely to improve profit margins.” Profit generation is only one way to judge AI tools, which are already being used to reduce clinician burnout and improve health outcomes. These kinds of applications will surely help providers’ bottom lines, but it might take a while for the financial impact to be measurable. Revenue cycle management, which is the top AI priority for providers this year, offers “hard-dollar ROI” more directly. Meanwhile, payers’ top priority is to automate utilization management and member care coordination. These efforts will often work against each other.
 
Providers want to use AI to generate cleaner claims and fewer denials. Payers want to manage medical spend by automating prior authorizations and steering patients toward high-value care. Whichever side develops the best AI applications the fastest will generate some portion of its profits at the other’s expense. Given that payers tend to have an edge on providers in terms of scale and technological sophistication, their AI tools may prove more effective at rationalizing care than providers’ tools at billing for care. However, the real winners of the payer-provider AI arms race could end up being the AI developers and tech platforms that get to sell their services to both sides.