From Burden to Breakthrough:
How AI is Transforming Healthcare Payer Operations
By 10Pearls editorial team
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The U.S. healthcare system is under pressure. Administrative costs account for over 40% of hospital expenditures, and nearly 30% of all healthcare spending is considered wasteful. Payers are not just grappling with mounting expenses—they’re navigating shifting regulations, star rating targets, and staffing shortages, all while trying to deliver better outcomes.
In our recent 10Pearls webinar, experts Amir Azarbad (10Pearls Managing Director, Healthcare Practice) and Peter Hesse (10Pearls EVP, Security & Compliance) joined tech journalist Zena Al Maskari to discuss how AI and workflow intelligence are helping payer organizations reduce costs, improve operations, and deliver more personalized care. Here are the biggest takeaways—and why they matter to healthcare payers looking for scalable, secure solutions.
1. Star ratings are financially critical—But hard to improve
Moving a Medicare Advantage plan’s star rating from 3.5 to 4.0 can mean an additional $20-30 million in reimbursements. Yet, achieving this is incredibly difficult. Regulatory shifts, evolving quality benchmarks, and economic uncertainty make it harder for payers to plan long-term strategies.
How 10Pearls helps:
We work with healthcare organizations to integrate AI-driven systems like our Decision Configuration Suite (DCS), helping them optimize the workflows and clinical actions that directly impact star ratings—without overhauling core infrastructure.
2. AI is key to optimizing care for high-cost claimants and minimizing risk
Payers face the challenge of managing patients whose care costs escalate rapidly year-over-year. Using machine learning and pattern recognition, AI can identify “next best actions” that proactively reduce costs and improve patient outcomes—like flagging when a member needs transportation to pick up prescriptions or support managing chronic conditions.
What 10Pearls has done:
For one large payer, 10Pearls implemented a longitudinal care management algorithm that aggregated socioeconomic and clinical data to predict cost jumps—and helped care managers intervene before patients’ conditions worsened.
3. AI tackles administrative bottlenecks that strain resources
AI isn’t just about predictive care. It’s also streamlining time-consuming manual tasks. From assigning case managers to triaging customer service calls, automation is helping payers drastically reduce administrative burdens.
What 10Pearls has done:
Peter shared a powerful stat: an organization using an AI-based scheduling system saved over six hours of nurse admin time per week—nearly a full workday per staff member.
Less busywork = less burnout.
It also improves productivity and reduces errors, both key to improving the member experience.
4. Data security and transparency are non-negotiable
With AI, the stakes around data governance are higher than ever. Patient data is deeply personal, and even minor missteps can lead to serious legal and reputational consequences. Ensuring compliance requires strong encryption methods (such as homomorphic encryption), well-defined AI governance frameworks, and transparent decision-making logic.
10Pearls’ approach:
Security is built into every solution we design. Our DCS platform allows users to trace decisions, audit processes, and maintain transparency—meeting HIPAA and other regulatory standards without slowing innovation.
Decision Configuration Engine (DCS)
DCS empowers businesses to set up decisioning criteria in a unified interface, enhancing governance and transparency across various applications.
5. Transparency builds trust in AI—and drives adoption
Healthcare is a high-stakes industry. A wrong AI-driven decision can have life-or-death consequences, which is why trust is often the biggest barrier to adoption. It’s essential that AI systems explain how they reach decisions—not just what they decide.
What 10Pearls delivers:
Our AI models are designed to be explainable. Whether it’s care recommendations or workflow automation, users can view the reasoning behind the output, increasing confidence among stakeholders.
6. Start with the end in mind—change management is critical
Implementing AI isn’t just a tech upgrade—it’s a cultural shift. Healthcare organizations need support in three key areas: optimizing processes, upgrading data readiness, and preparing people for change.
Our strategy:
We partner with clients to co-create a roadmap that focuses on quick wins—like reducing manual workflows—and gradually scales toward more advanced AI applications like automated prior authorization. This phased approach ensures adoption while delivering ROI early.
7. The future: AI-powered self-healing workflows and multimodal models
Looking ahead, here are two areas to watch:
- Self-healing workflows: AI that can detect bottlenecks and autonomously resolve them.
- Multimodal AI: Combining everything from genome data to social determinants of health to deliver radically personalized care recommendations.
10Pearls is already helping clients prepare for this future by investing in sandbox environments, cloud and on-prem infrastructure, and governance-first implementation models.
Why partner with 10Pearls?
At 10Pearls, we don’t just build software—we deliver strategic, secure, AI-powered transformation tailored to your business goals. Whether you’re trying to reduce operational overhead, improve member outcomes, or future-proof your digital ecosystem, we bring healthcare-specific expertise and enterprise-grade innovation to the table. Healthcare payers are facing urgent pressure—and untapped opportunity. Let’s build the systems that help you meet both.
Ready to talk AI in healthcare? Let’s explore how 10Pearls can help modernize your operations—securely and strategically.
Our webinar speakers
Peter Hesse is EVP & Partner at 10Pearls, where he oversees global delivery and compliance across the organization. Peter focuses on embedding security and governance into digital transformation initiatives across industries. Peter has over 25 years of experience in technology, Peter has consistently delivered innovative solutions that balance technical integrity, security, and usability.
Amir Azarbad is the Managing Director of 10Pearls Healthcare Practice, focusing on strategic and technology solutions. He has over 20 years of healthcare experience and has helped organizations transform their legacy solutions to reduce administrative costs while increasing automation and enabling business configurable solutions.
Get in touch with us
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