AI in Healthcare Starts Long Before the Exam Room

Why It Matters

Without addressing benefits navigation, AI cannot curb overall healthcare spend or improve employee satisfaction, making it a critical focus for employers and insurers.

Key Takeaways

• Clinical AI improves diagnosis, not cost transparency.
• Administrative complexity wastes up to $265 B yearly.
• Navigation AI can cut employee healthcare coordination time.
• Out‑of‑network billing creates unexpected $37k debt.
• Employers benefit from AI‑driven benefits guidance.

Pulse Analysis

The hype around clinical artificial intelligence often eclipses a fundamental flaw in the U.S. health system: patients still cannot determine whether a provider is in‑network before they walk through the door. Even as AI algorithms achieve near‑human accuracy in imaging and triage, the administrative layer remains opaque, leading to surprise bills like the $37,000 charge described in the article. This disconnect erodes trust and limits the broader adoption of AI‑enabled care, because cost uncertainty outweighs clinical benefits for many consumers.

Administrative simplification offers a massive, untapped lever for cost reduction. McKinsey estimates that streamlining documentation, billing, and workflow could save $265 billion each year, dwarfing the incremental savings from diagnostic AI alone. Navigation‑focused AI can bridge the information gap by instantly verifying network status, estimating out‑of‑pocket costs, and guiding patients to appropriate facilities. Such tools reduce the average eight hours per month employees spend on scheduling and billing tasks, translating directly into higher productivity and lower turnover for employers who sponsor health plans.

For benefits leaders, the strategic choice is clear: expand AI investments beyond the exam‑room to encompass the entire care journey. Countries like China and Singapore are already integrating clinical and administrative AI under unified regulatory frameworks, delivering smoother patient experiences and predictable expenditures. U.S. employers can emulate this model by deploying AI‑driven benefits navigation platforms that operate within existing compliance boundaries, delivering immediate, measurable ROI while laying the groundwork for future clinical AI rollouts. The true benchmark for healthcare AI success will be whether patients receive care without unexpected financial shock.

AI in healthcare starts long before the exam room

By Guy Benjamin, Co‑Founder and CEO, Healthee; Venture Capitalist and Founding Partner, Group 11

Picture this: An autonomous AI emergency room physician performs a flawless intake, triage and diagnosis of a patient's intense knee pain, cutting wait times by 30%. The patient needs surgery to repair torn tendons. The procedure goes perfectly.

They go home thrilled with the experience.

Then the $37,000 bill arrives.

The surgeon was out of network. No one told them. The patient's health plan has 0 % coinsurance for out‑of‑network care. The entire cost falls on them. What follows is an eight‑month fight to avoid medical debt.

This is the future we are racing toward, not because AI failed clinically, but because the system around it stayed exactly the same.

Healthcare AI is advancing quickly. Proposals like 8VC’s A Vision for Healthcare AI in America outline a future where artificial intelligence can diagnose, treat and even bill for medical services. It is an ambitious and necessary vision. But it assumes patients can navigate the healthcare system well enough to reach these AI‑powered providers in the first place.

We could implement every proposed clinical AI reform tomorrow and patients and plan sponsors would still see little financial relief if people continue showing up at the wrong facilities, under the wrong coverage, at the wrong price.

The breakdown happens before care begins

Before arriving at the hospital, the patient made a reasonable attempt to determine whether the ER was in‑network. Their employer’s benefits portal was down. The insurer’s phone line had a 75‑minute wait. The hospital website listed outdated insurance information. In severe pain, waiting for clarity was not an option.

This scenario plays out daily across the U.S. healthcare system.

Significant resources are being invested in AI that can interpret medical images and assist with diagnoses, while employees still struggle to answer basic questions about coverage. Time is being saved during clinical encounters while delays and confusion increase before care begins and after it ends. Those are the moments that determine whether care becomes financially devastating.

McKinsey estimates that administrative simplification could save up to $265 billion annually in U.S. healthcare costs, largely by reducing documentation errors, billing complexity and redundant workflows. Yet most innovation and regulatory attention remains focused on clinical workflows rather than the administrative and navigation layers that drive a large share of unnecessary spending.

Advanced medical centers now offer sophisticated AI‑enabled care, but employees often cannot reliably find them, confirm coverage or understand cost exposure ahead of time. High‑quality care is paired with unpredictable financial outcomes.

After discharge, complexity accelerates

After months of appeals, phone calls and applications for financial assistance, the patient’s $37,000 bill is reduced to $12,000. The amount is lower, but still financially damaging.

Medical debt in the U.S. exceeds $220 billion, affecting tens of millions of Americans. The consequences extend beyond finances. People delay care, experience anxiety and lose trust in the healthcare system. Many also lose confidence in their employers, who sponsor and administer these plans.

Current visions of healthcare AI tend to stop at the exam‑room door. That is where administrative complexity increases, not decreases. Introducing autonomous AI providers without addressing navigation and billing infrastructure risks adding new failure points. Claims from AI‑driven providers may not be recognized by insurers, leaving employees to pay out of pocket and pursue reimbursement on their own.

For employers and benefits leaders, this gap has direct financial consequences.

The U.S. spends about $4.5 trillion annually on healthcare. A substantial portion is lost to administrative complexity, poor navigation and avoidable billing errors. Clinical AI addresses only a fraction of that waste. Benefits navigation and administrative clarity represent a far larger opportunity for cost control.

Employers consistently report rising healthcare costs alongside declining utilization. The 2024 KFF Employer Health Benefits Survey shows continued growth in premiums and cost sharing, even as employees struggle to use benefits effectively. Existing point solutions address isolated problems but rarely guide employees across the full care journey.

Navigation‑focused AI faces fewer regulatory hurdles than clinical AI. It does not diagnose or prescribe. It can help employees identify in‑network care, understand coverage and avoid financial surprises. The impact is immediate and measurable.

Roughly 160 million Americans receive health coverage through employer‑sponsored plans. Employers fund the system policymakers and innovators are attempting to reform. Any meaningful AI healthcare strategy must include them.

Benefits leaders need tools that help employees make informed decisions before care begins. HR teams need scalable support for answering complex coverage questions. Providers benefit when patients arrive with realistic expectations about cost and reimbursement.

Administrative and navigation AI should be treated as core healthcare infrastructure. Other countries are already moving in this direction. China and Singapore are building integrated healthcare AI systems that combine clinical, administrative and navigation capabilities under clear regulatory frameworks.

A choice ahead

One path forward prioritizes clinical AI while leaving the surrounding system unchanged. In that scenario, advanced care exists, but access and affordability remain uneven. Employees who understand the system fare better than those who do not.

Another path expands the definition of healthcare AI to include the full journey, from first symptom to final payment. This approach focuses on helping people find appropriate care, confirm coverage and avoid preventable financial harm.

Employees already spend an average of eight hours per month coordinating healthcare tasks such as scheduling appointments and resolving billing issues. These hours translate directly into lost productivity and growing frustration. Research also shows that better benefits experiences are linked to higher retention, fewer sick days and improved productivity.

For benefits leaders, the priority is practical. Employees want to know where to go, what is covered and what they will owe. Solving those problems does more to improve trust and outcomes than adding new layers of clinical automation alone.

The real progress in healthcare AI will be measured by whether patients can seek care without fear of financial consequences they never anticipated.