In Healthcare insurance domain, the most unexpected and unorthodox way of creating an AI model using Prompt and Flow-based AI designing would be Automated Provider Credentialling Clarification Assistant.
The Rationale:
Use Case: In Provider Data Management division of a Healthcare insurance organization, one of the most time-consuming and error-prone process is Credentialling.
Credentialling process involves verifying a provider's qualifications, licenses, affiliations, practice details etc.
Providers or their billing offices submit forms and documents to the insurance with required info to get them credentialled.
Almost every time, credentialling team must go back and forth with providers to clarify missing or inconsistent information in submitted documents or forms, the FTR rate typically are in between 12 - 20%.
The process is mostly manual, slow and prone to delays, which affects provider onboarding and claim processing timelines.
How to use Flow+Prompt-based AI design to solve this problem:
Trigger: When a provider submits a credentialling request, the system should check for missing, inconsistent, or ambiguous data. The triggers will be detected using:
Rule-based checks,
Data validation scripts,
Simple ML classifiers, flagging inconsistent entries based on historical patterns
Prompt Engine: A prompt-based AI agent will be triggered. This agent will:
Generate a NL (natural language) clarification request designed for the specific issue, and
Ask follow-up questions (if needed).
It will use template-based prompts with dynamic slot filling.
In case of ambiguous answers, AI will follow-up with a more specific question.
In case of multiple issues, AI will prioritize and address them one at a time.
Flow Logic:
If the provider responds with valid data, the system will update the record and move on to the next step.
In case of unclear or incorrect answers, AI will follow-up with a more refined prompt.
If no response received within a set-time, the case will be sent to a human reviewer.
Steps:
Detect Issue -> Trigger AI
Send Prompt -> Wait for provider to respond
Evaluate response
Valid -> Update System -> Mark as Issue Resolved
Unclear -> Send follow-up prompt
No response in pre-defined timeframe -> Escalate to human reviewer
Loop until all issues are either resolved or the case is escalated.
Embed the solution within existing credentialling platforms.
Constantly review and update the KB to ensure the model learns from provider responses and improve future prompts and reduce friction.
The Why: Because it's unconventional, high-value, scalable & cost-effective.
Novelty: Prompt-based AI solutions in healthcare are mostly used to answer FAQs, or claims status checks. Using it for Credentialling solution, especially when embedding the solution to the existing credentialling platforms has a novelty factor.
High Value: This solution will address a high-friction, yet low-visibility pain point.
It will reduce onboarding time for providers.
It will minimize manual back-and-forth between the business and providers.
It will improve data accuracy, impacting directly to the downstream processes (ex: claims adjudication).
Scalable & Cost-effective: Being a LLM based model, enhanced by flow and prompt engineering, it will save cost and add value to the business.
Retraining of the models won't be needed, we can design smarter prompts and flows.
Can be deployed across multiple provider types and regions with bare minimum customization.