Healthcare
Discover how healthcare payers can overcome A&G challenges with automation and Agentic AI. Prashant and Vijeet share insights on streamlining workflows, strengthening compliance and driving member satisfaction—transforming appeals management into a catalyst for efficiency and cost optimization.
Mimi: Hello and welcome to the Infosys BPM podcasts. I’m Mimi, back with another exciting episode.
Today we’re talking about an area that’s mission-critical for healthcare payers — appeals and grievances management or as I shall address it as A&G Management. With growing regulatory pressures, rising member expectations and operational complexities, payers are under pressure to balance compliance, efficiency and experience.
Joining me today are Prashant Ramineni, who leads healthcare solution design at Infosys BPM and Vijeet Sareen, Senior Services Head of client operations.
Together, they’ll walk us through the challenges and more importantly, how automation and Agentic AI are transforming A&G outcomes across healthcare.
Welcome to the podcast, Prashant and Vijeet.
Prashant: Thanks, Mimi. I’m excited to be back here with another podcast.
Vijeet: Thank you, Mimi. Looking forward to having an engaging discussion.
Mimi: Awesome & thank you both for joining!
Prashant, my first question is to you. Let’s begin with the big picture. What are the core challenges healthcare payers are facing in the area of A&G today?
Prashant: Thanks Mimi, that’s a great starting point. The A&G landscape has become increasingly complex. Think about it—payers still rely on manual, fragmented workflows, often juggling multiple disconnected applications just to process a single appeal. It’s frustrating for teams and creates inefficiencies that ripple across the system.
The appeals process is at a tipping point. Massive denial volumes combined with rising appeal rates are driving operational overload, missed service commitments and compliance risks. These backlogs and delays don’t just slow things down—they impact member and provider experiences and erode payer performance.
Misrouting is another major challenge. When appeals are tagged incorrectly, it leads to rework, higher costs and slower resolution. Delays in processing remain one of the top compliance challenges for payers. For providers, these delays translate into mounting administrative overhead and prolonged revenue cycles, adding strain to already tight margins.
Payers face constant pressure to ensure timely, accurate processing to stay compliant with regulatory standards. Meanwhile, providers absorb the operational and financial impact of these delays across the care continuum.
At the heart of all this is a human story—members and providers waiting for answers, teams doing their best with limited tools and organizations struggling to keep pace. It’s a tough balancing act and it’s time we rethink how we approach it.
Mimi: Prashant, that gives a lot to think about, doesn’t it?
Vijeet, from your vantage point and experience in the market, how are payers shifting their priorities to address these challenges?
Vijeet: Great question, Mimi. I would say, payers today are very clear about their priorities. At the top of the list is the need to streamline and automate A&G processes, because manual handling just can’t keep up with the scale anymore. They’re also laser-focused on reducing turnaround times and improving accuracy, since every delay directly impacts member satisfaction.
At the same time, payers are under pressure to manage costs and stay compliant. To put this in perspective, a Health Affairs study in 2023 noted that administrative costs account for nearly 15–30% of total U.S. healthcare spending and A&G is a significant contributor. So, efficiency isn’t just a nice-to-have feature; it’s critical for financial sustainability.
What we are seeing now is a shift, payers are moving away from fragmented, reactive approaches toward proactive, automated and data-driven operations that can scale — giving them the agility to handle today’s volumes while being ready for tomorrow’s demands.
Mimi: So, Prashant, this scalability and automation are key factors for the future of healthcare A&G operations.
Is this where automation and Agentic AI step in to make a difference?
Prashant: Exactly, Mimi, scalability and automation are no longer optional—they’re foundational for the future of healthcare A&G operations. This is exactly where automation and Agentic AI come into play. Traditional automation helps streamline repetitive, rules-based tasks, reducing manual effort and improving accuracy. But Agentic AI takes it a step further—it’s not just executing tasks, its reasoning, adapting and making decisions in real time.
Imagine an AI agent that can analyze complex claims, identify anomalies and even recommend next steps without human intervention. It can dynamically learn from patterns, handle exceptions intelligently and collaborate with other systems to deliver end-to-end automation. This means faster turnaround, fewer errors and a better experience for both members, payers and providers.
Agentic AI in A&G centralizes workflows, enables smart routing for timely resolution and supports audit readiness. It learns from outcomes to improve processes and helps payers and providers handle high volumes and exceptions without losing accuracy or member experience, making A&G a proactive driver of efficiency.
So yes, automation lays the foundation, but Agentic AI is the game-changer—it brings intelligence, autonomy and scalability to operations that were previously constrained by manual processes.
Mimi: Thank you, Prashant, it really sounds like the technologies you're talking about aren't just upgrades; instead, they're game-changers for the industry!
Vijeet, is there any success story that comes to your mind, where technology has played a key part?
Vijeet: Yes Mimi, we do have plenty of examples of bringing transformation. For one of our payer client…
