Sanjay Mohan

Submitting and processing medical claims has long been a pain point for both customers and insurers—think paperwork, long waits, and complex documentation. But AIA is changing the game. We’ve harnessed the power of Generative AI to streamline and simplify the claims journey, making it faster, smarter, and more customer-centric. Read more in this piece by Claudio Caula, Director of Group Data Analytics and Artificial Intelligence at AIA, published on Insurance Asia https://lnkd.in/g8y3aYE8 #TDA #HealthierLongerBetterLives #AITransformation #InsuranceInnovation #GenAI #OperationalExcellence #DigitalInsurance

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Excited to formally announce Collective Health's expansive AI partnership with Google Cloud for our core AI infrastructure and development frameworks. After evaluating all of the major AI and foundational model companies out there, it was clear that Google Cloud was the right partner for us at Collective Health given their breadth of AI development tools, level of foundational model investment, and focus on user privacy and safety. Thank you Aashima Gupta, Amin Vahdat, Anas Osman, Hamidou Dia, Jeff Dean, and Sundar Pichai for your partnership and support of our AI efforts at Collective Health. Here's to transforming America's health insurance and health benefits industries together by harnessing the near-limitless power of Google Cloud's generative AI stack. https://lnkd.in/gJXGbeJB

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🎙️ Episode 164 is here! Meet Dean Fadel, the industry veteran who's seen it all—and lived to tell about it. After 37 years as President and CEO of Ohio Insurance Institute, Dean brings unparalleled perspective on where insurance policy meets innovation reality. What makes this conversation essential: 🚀 AI in Action: How ChatGPT became a "lifesaver" for underwriting when Ohio's auto plan exploded from 12 policies to $45M overnight ⚖️ Regulatory Reality: Why TPAs are now applying for AI claims adjuster licenses—and what that means for our industry's future 📊 Workforce Crisis: Ohio needs 108,000 insurance workers by 2031. How are we preparing? 💰 Hidden Costs: The shocking truth about how lawsuit billboards drive up prices on everything from eggs to insurance 🤝 Ethical Leadership: "I've never felt ethically conflicted with any position I've had to advance"—what 37 years of principled advocacy looks like Dean doesn't just observe change—he navigates it. From the Uber regulatory moment to AI licensing, he's been at the table for every major shift. Perfect for: Insurance executives, InsurTech founders, policy professionals, and anyone curious about how innovation and regulation actually work together. 🎧 Listen now: https://lnkd.in/eT-rNMD6 #InsurTech #InsuranceLeadership #PolicyInnovation #RegulatoryStrategy #AIinInsurance

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Allegations from Illinois reveal a troubling case of Medicaid fraud targeting vulnerable populations. A home-health worker is accused of forging timesheets and submitting false claims over several months. The charges include healthcare fraud, theft, and forgery—reflecting the serious breach of trust and integrity. Investigators estimate tens of thousands of dollars in illicit claims, threatening the stability of vital care programs. If you manage in-home services, ensure your staff uses GPS-verified clock-ins, patient confirmation, and conduct regular audits. Patients and families, review your explanations of benefits carefully, and report any discrepancies or unfamiliar charges. Integrity checks protect both caregivers and the people they serve. Staying vigilant helps prevent fraud that hijacks vital care resources and jeopardizes recovery efforts. #MedicaidFraud #HealthcareIntegrity #PatientProtection #HomeHealth #CareTransparency #FraudPrevention #HealthAndSafety #TruthInCare #PMGGuides #HealthSecurity

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We're eliminating the guesswork on how to curtail health spend. Our actuaries are helping health plans identify the costs that actually move trend. Great insight Stuart Sutley. https://lnkd.in/ennsPScY

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Large medical claims and lasers in stop-loss insurance can disrupt even the best-designed health plans. The right strategies—like predictive analytics, reserve funds, and negotiated terms—can mean the difference between stability and financial strain. #JMRBenefitStrategies #EmployeeBenefits #HealthPlans #RiskManagement #StopLossInsurance #BenefitsStrategy #HealthcareCosts #HRLeaders

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How Do Actuaries Model Healthcare Costs?? Learn the Step-by-Step Process to Project an Employer-Sponsored Health Plan's Spend. Step 1: Gather Historical Data... 24-36 months of claims data (both paid and pending claims) along with monthly plan member enrollment data Step 2: Calculate the Historical Per Member Per Month (PMPM) Cost Step 3: Apply Trend incorporating medical cost inflation, utilization changes, new treatments/drugs and regulatory changes Step 4: Adjust for Plan Design Changes such as changing the deductible and total cost share, using a narrow network or benefit enhancements Step 5: Exclude High Cost Claimants Step 6: Adjust for Demographic Changes within the population Step 7: Add a Risk Margin of 2-5% to allow for error Step 8: Benchmark the PMPM against other similar groups and create three final PMPMs: High, Mid and Low estimates of healthcare costs. Sources at AHealthcareZ YouTube Channel. #Actuary #Healthcare #HealthcareCosts #HealthInsurance

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