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AI and member experience: Where innovation meets human insight

Published Date
Author Karen Way, MHA

The healthcare industry generates an astonishing amount of data. A typical hospital produces 50 petabytes of data per year, and, given the explosion of healthcare data, AI has become indispensable for managing and making sense of it.  

AI-driven technologies like robotic process automation (RPA), natural language processing (NLP), and machine learning help health plan organizations process and analyze data and extract meaningful insights at an unprecedented pace. These technologies enhance member experience (MX), drive better health outcomes, and lower costs—supporting the goals of value-based care.

While AI presents remarkable opportunities, it isn't without its challenges. And the stakes are high—especially in healthcare. Yes, AI processes vast amounts of structured and unstructured data at unmatched speed and scale. But it lacks the ability to apply empathy, context, and ethical judgment to insights and decisions.

Without proper safeguards, AI can introduce bias, misinterpret member needs, or prioritize cost savings over care quality. When introducing AI into health plan operations, “it is important to be clear about what AI is not good at…making causal determinations will still require classic hypothesis testing.” Several health plans are currently facing class-action lawsuits regarding the use of AI in utilization management determinations, with nine out of 10 denials being overturned upon appeal. These risks underscore the need for careful oversight, clear guidelines, and human input when using AI in healthcare.

Striking the right balance between artificial intelligence and human ingenuity

AI should enhance—not replace—Human Experience and judgment. While it can streamline processes, identify patterns, and personalize member interactions, what it can't do is stand in for human connection and compassion, empathy, and critical thinking.

This balance is especially crucial in health plan member experience, where trust, perception, and communication are just as important as efficiency and accuracy. Health plans must be pragmatic in AI adoption—leveraging its strengths while maintaining ethical safeguards and transparency.

5 things health plans should consider when implementing AI

  1. Ensure the AI solution is “fit for purpose.” Using AI as a means for cost reduction and process efficiency should not be the only considerations. We need to bring its impact on the quality of care and member outcomes into the equation as well.
  2. There’s still a lot to learn about using AI in healthcare. We should look to other industry verticals and leverage their learnings, best practices, and potential pitfalls.
  3. Unintended bias is a real concern. You have to think about what data is being used to train AI. Does it adequately represent a broad spectrum of member personas, or does it focus on a specific subset of people? For AI to make a real impact in healthcare, it must follow the first approach, not the second.
  4. AI governance is critical. A new form of AI, agentic AI, has recently entered the healthcare space. Agentic AI is a form of artificial intelligence that lets AI systems act autonomously, making decisions and taking actions without continuous human supervision. Organizations must align their strategy and governance with evolving technology.
  5. Maintain healthcare’s humanity. This means the empathy, compassion, and, yes, the emotions that are part of being human. To achieve this, we should think about AI as “augmented” intelligence, complementing and working alongside the people in the healthcare industry.

AI can help you develop richer patient and member personas, identify unintended biases, and create a full longitudinal view of healthcare experiences. And Press Ganey is uniquely positioned to help. With one of the largest repositories of member and patient experience data, we can uncover deep insights and reveal key patterns around how individuals interact with the healthcare system, and where improvements are needed. AI-driven analytics can help healthcare organizations better understand member needs, streamline processes, and personalize experiences, ensuring that technology enhances—not diminishes—the human side of care.

The future of artificial intelligence in member experience

Studies show that 94% of healthcare executives see analytics as critical to improving customer experience. AI and data-driven insights will continue to shape how healthcare organizations engage with members, optimize operations, and drive better outcomes. But as we move forward, we must ensure AI is used responsibly—balancing technological advancements with ethical considerations, human oversight, and a relentless focus on quality care.

At the end of the day, AI isn’t a magic wand that will solve all of healthcare’s challenges. It is a powerful tool that, when used thoughtfully, can—and will—drive real impact. The key lies in balancing automation with humanity, efficiency with empathy, and data with trust. That’s how we ensure AI enhances the healthcare experience and improves people’s lives.

To learn more about AI and the member experience, reach out to a member of Press Ganey’s health plan team.