Interviews × AI Engines × Benchmarks — Executive Readout

Multi-Source Integration Framework

• Fusion model: interviews (coded themes) + AI answer signals + plan benchmarks.
• Validation: cross-check AI outputs with authoritative artifacts (policies, PA grids, formulary, filings).
• Triangulation: theme ↔ metric ↔ AI-signal agreement threshold ≥ 0.7 for inclusion.

Interview Methodology

• Sample: 38 interviews (7 exec, 11 ops, 9 clinical, 11 members/caregivers).
• Semi-structured guides on PA, claims, benefits, directory, service.
• Double-coding, Cohen’s κ = 0.81; discrepancies adjudicated weekly.

AI Engine Integration

• Models: ChatGPT, Claude, Gemini, Perplexity (answer engines); policy/document retrieval checks.
• Pipelines: transcript NLP (topic, sentiment, stance) → entity/intent → evidence linking.
• Human-in-the-loop QA: outlier review, hallucination filter, policy anchor verification.

Data Collection Architecture

• Primary: stakeholder interviews, member focus mini-groups.
• AI-gathered: sentiment from public reviews & forums; policy coverage crawl.
• Benchmarks: Stars/HEDIS extracts, MLR & 10-K/K-1, CMS PA timeliness, directory audits.

Qualitative Analysis Engine

• Top themes: “PA clarity”, “EOB transparency”, “Directory trust”.
• Theme stability tested across groups; drift flagged for exec review.

Quantitative Benchmark Analysis

• Percentiles shown for Stars, HEDIS, MLR, PA timeliness, FCR (service).
• Forecast models (ARIMAX) align with interview-derived risk/driver tags.

Cross-Validation Protocols

• Answer engines must cite a canonical policy/FAQ to count toward “presence”.
• Interview claims matched to benchmark metrics within ±1 quarter.
• Contradictions trigger human review and corrective sourcing tasks.

Correlation Explorer

Example: ↑ policy citation authority correlates with ↓ PA denials (r = -0.58).

Pattern Recognition & Synthesis

• Convergence: Interviews + AI agree “PA criteria discoverability” is primary friction.
• Divergence: Executives rate service FCR higher than member interviews; reconcile via QA sample.
• Mapped indicators: PA policy coverage → denials, directory accuracy → Stars access measures.

Gap Analysis Framework

Area	Interview Perception	Benchmark Reality	Gap
PA Timeliness	“Inconsistent”	95th pct = 72 hrs	Target ≤ 48 hrs
Directory Accuracy	“Unreliable”	Audit pass 87%	Goal ≥ 95%
EOB Clarity	“Jargon heavy”	CSAT 3.7/5	Goal ≥ 4.2

Stakeholder Perspective Mapping

• Executives: Focus on Stars and medical cost trend.
• Operations: Prior auth rules and cross-team handoffs.
• Clinical: Criteria transparency, exception workflows.
• Members: PCP selection, cost clarity, digital claims status.

AI-Enhanced Competitive Analysis

• Automated peer monitoring: PA pages, formulary tiers, turnaround SLAs.
• Signals point to rising self-service in two markets (Perplexity coverage +22%).
• Emerging risk: inconsistent state variants create answer drift in AI Overviews.

Scenario Modeling

Action Priority Matrix

Impact × Feasibility; bubble size = cost. Prioritize top-right (high/high).

Data Integrity Protocols

• Transcript QC: completeness, speaker tagging, redaction audit.
• AI output checks: policy anchor present, date validity, locale match.
• Benchmark provenance: source IDs, refresh cadence, coverage notes.

Bias Detection & Mitigation

• Interviewer/participant bias monitored via balance scores.
• Model bias tests across question phrasing & locales.
• Benchmark selection sensitivity analysis (exclude/replace tests).

Executive Dashboard

• Integrated KPIs, qualitative context, AI trend alerts.
• Evidence map: each insight → sources (interview quote, policy URL, metric).

Detailed Analysis Sections

• Interview findings with representative quotes and theme codes.
• AI engine results & methodology; benchmark tables/visuals.
• Joined conclusions with traceable evidence chains.

Continuous Intelligence System

• Quarterly interviews, monthly AI re-runs, benchmark refresh.
• Automated alerts: policy drift, directory integrity, PA SLA variance.

Action Tracking

Initiative	Owner	Status	Metric
Canonical PA pages	Clinical Ops	In flight	PA 95th pct ≤ 48h
Directory verification	Provider Net	Pilot	Accuracy ≥ 95%
EOB simplification	Member Exp	Design	CSAT ≥ 4.2