2026 AI Trends Series, Part 1: Carrier-level Observations in Employee Benefits

TruePlan’s six main observations from carriers this year

Artificial intelligence continues expanding across the employee benefits landscape. According to the 2025 NAIC Artificial Intelligence and Machine Learning (AI/ML) Survey Report 84% of health insurers report they currently use AI and machine learning in some capacity. Adoption appears to be deepening operationally this year within employee benefits programs.

In this blog, we'll examine several ways insurers are using AI to improve efficiency and decision-making. At the same time, we'll highlight some of the challenges associated with AI adoption, including concerns that it enables insurers to more easily challenge clinical decisions and automatically deny coverage, affecting provider payments and patient access to care.

1. Claims processing and adjudication

Carriers are using AI to automate and streamline claims processing. Insurers report the following impacts:

• faster approvals or denials for some claims;

• more efficient adjudication; and

• accelerated provider payments for some claims.

Automation can reduce manual review time while increasing consistency, but the process isn't without controversy. Insurers say billing formats from provider notes generated by AI can cause up-charging. Conversely, healthcare providers say insurers’ use of AI simply makes it easier for insurers to override clinical decisions and deny coverage to the detriment of provider payments.

2. Prior authorization and pre-certification reviews

Carriers are applying AI to prior authorization and pre-certification workflows. Insurers ostensibly use these tools to:

• guide clinical decision support;

• flag incomplete documentation; and

• reduce administrative delays.

However, the balance between efficiency and clinical oversight is not always maintained: AI can also enable insurers to more efficiently deny or delay paying claims to providers.

3. Fraud detection and data monitoring

AI-driven analytical tools are identifying:

• mismatched data;

• suspicious billing patterns; and

• outlier utilization behavior.

Predictive modeling enables earlier detection within the claims cycle.

4. Workflow enhancements

Beyond claims, AI is embedded in internal operational workflows.

This includes:

• administrative task automation;

• case routing optimization; and

• volume management.

Carriers appear focused on operational scalability. Again, it’s important to note that while it may help insurers with workflows, insurance carriers can use AI to identify which claims to deny automatically.

5. Tailored care recommendations and proactive outreach

AI tools are analyzing claims and using data to identify members with chronic conditions, such as diabetes.

Observed capabilities include:

• flagging at-risk members;

• triggering outreach campaigns;

• encouraging preventive care; and

• attempting to reduce avoidable future claims.

This reflects a broader shift toward predictive engagement.

6. Enhanced customer experience and transparency tools

Carriers continue expanding AI-enabled member-facing tools, including:

• virtual assistants;

• optimized provider search tools;

• personalized benefit navigation;

• out-of-pocket cost estimators; and

• benefits understanding tools.

The emphasis appears to be on improving transparency and simplifying complex plan designs. However, there’s not enough public data or use cases to determine the definitive impacts of these tools.

What’s next: Broker-level AI adoption

At the broker level, AI discussions in 2026 increasingly center on:

• supporting plan sponsors faster;

• improving overall plan experience;

• enhancing plan fit; and

• managing and forecasting costs.

Final thoughts

AI is firmly embedded within carrier operations in 2026. From claims automation to member engagement and transparency tools, implementation appears focused on speed, efficiency, predictive analytics and improved user experience. However, healthcare providers also see AI being used to advance insurers' ability to delay or deny coverage, drawing increased scrutiny from state regulators, CMS and provider organizations concerned about automated decisions replacing clinical judgment.

This is what we’re observing across the employee benefits space today. If you have questions about other emerging trends, contact us.