Aetna Uses AI to Simplify Healthcare Navigation for Members
CVS Health's Aetna is deploying conversational AI tools and personalized guidance systems to reduce the administrative burden on patients navigating benefits, finding providers, and managing their health data. Nathan Frank, the insurer's chief digital and technology officer, said the technology addresses a fundamental gap in healthcare delivery.
"We believe that it's going to change the consumer healthcare experience," Frank said in an interview. "We think it's going to continue to advance the clinical experience and really improve the ability for us to meet our members and provide better clinical outcomes."
How the AI Assistant Works
Aetna embedded an "Ask Anything" capability across its app and web properties, allowing members to ask questions in natural language and receive responses that might include provider maps, next steps, or relevant information they hadn't considered. The system uses something called GenUI to personalize each response.
The approach reduces call center volume. Members who get quick answers online skip the phone call entirely. But Aetna recognized that healthcare is personal - some members with chronic conditions or recent diagnoses want to speak with a representative.
The company extended the same AI tools to its member services representatives on the back end. When a member calls, the representative already knows who they are, what digital questions they asked, and what answers to anticipate. This lets staff focus on empathy rather than scrambling for information.
Preventing AI Errors and Bias
Frank emphasized that Aetna treats AI as transparent and explainable, not a black box. The company built guardrails to prevent bias and hallucinations, then monitors performance constantly.
Clinical experts - nurses and clinicians - sit in small development groups and provide instant feedback. When AI summarizes clinical information, Aetna relies on its 15,000 nurses to flag problems or confirm what works. This feedback loop proved essential for maintaining accuracy.
"We want to make sure those 15,000 nurses have the ability to say, 'Hey, that didn't work properly' or, more importantly, after an interaction: 'That worked awesome,'" Frank said.
Monitoring and Tuning at Scale
Aetna uses product managers and engineers to monitor and tune systems in real time, supplemented by regular retrospective reviews of data and usage patterns. The company also tracks front-end user experience and feedback.
The insurer started small with clinical call summarization, ran tests, verified transparency and measurement, then expanded gradually as confidence grew. This test-and-learn approach allows tuning before wider rollout.
Results So Far
Aetna's Care Paths product guides patients with specific conditions through their benefits and next steps. For maternity, diabetes, and musculoskeletal conditions, the tool reduced calls by 8.6% while increasing digital engagement by 38%.
A pregnant member can opt into the maternity Care Path, see a personalized view of their benefits and next steps, and ask their provider targeted questions. If they want live support, they click a button to reach a care manager.
Customer satisfaction has risen as the digital experience improved. Frank noted that success looks different for different members - some prefer phone calls, others want digital-only options. The data shows members are choosing the digital path when it works well.
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