Conversational AI Improves Healthcare Member Experience

Conversational AI Improves Healthcare Member Experience

7 min read

Quick guide for health insurers

For health insurers, the challenges presented by the pandemic exacerbated many of the industry’s pre-existing conditions around member satisfaction and escalating costs:

Fortunately, these problems aren’t incurable. Recent advances in conversational artificial intelligence (AI) are proving highly effective in helping insurers overcome the challenges around member experience, while AI-powered automation applies intelligent analytics to address the claims overpayment problem.

This ebook covers four “treatments” that use conversational AI, automation, and other advanced technologies to deliver a positive, frictionless experience for members and agents while reducing costs.

“83% of healthcare organizations have implemented an artificial intelligence strategy, while another 15% are planning to develop one”

Source: “Third Annual Optum Survey on AI in Health Care,” Optum, October 2020.

Driving strategic outcomes for health insurers

Using conversational AI and automation, health insurers can:

Improve member experience, satisfaction and loyalty

Increase contact center efficiency and scalability

Reduce costs

Catch overpayment before it happens

Improve agent experience, satisfaction, and retention

Source: “Why Contact Centers Are a Key Part of a Human+Digital Banking Strategy,”
Kevin Halsey, The Financial Brand, December 2020

Apply Conversational AI to Member Self-Service

Improving the member experience starts by understanding and optimizing every conversation before, during, and after an agent/member interaction. Often the conversation starts in a self-service channel. Using conversational AI, health insurers can increase self-service and automation rates and deflect transactional interactions from contact center agents — all while delivering an optimized member experience.


  • Contact center agents are overwhelmed with calls, including many that could be resolved more quickly and easily with intelligent self-service.
  • Members face long wait times to get answers to simple questions such as coverage information, claim status, provider inquiries, and others.
  • Members trying to use self-service who are unable to quickly find the answer to their questions must start over in a new channel, increasing their frustration.


  • Intelligent virtual assistants (IVAs), also known as chatbots, drive the completion and personalization of the member self-service experience.
  • Conversational self-service engages members for routine transactional payer journeys, such as claim status updates, new policy inquiries, mailing of insurance cards, provider and office hours look-up, and appointment scheduling.
  • Higher-need inquiries are automatically transferred to agents for more personalized care.
  • A single IVA can effectively service thousands of members, giving them easy access to information anywhere and anytime.


  • Reduces contact center call volume, call waiting times, and costs.
  • Improves member satisfaction.
  • Improves member and agent experience because conversational AI alerts the agent to customer sentiment and intent as well as next best actions and recommendations.

Reduce Friction in the Member Journey

Conversational AI optimizes every conversation by enabling agents to be more productive and empathetic while personalizing the experience for members. With a conversational AI and automation platform that can understand the customer’s real intent, emotions, and implied needs, contact centers can deliver a more conversational experience that eliminates friction in the member journey and
improves member satisfaction.


  • Members are frustrated or disappointed because it takes too long for agents to understand their needs and resolve their issues and queries.
  • Agents are frustrated because they can’t quickly resolve member issues and aren’t able to work efficiently.
  • Member satisfaction and loyalty remain low because members aren’t getting the customer service experience they expect from their health plan
  • Contact centers lack insight into trends and patterns to help them make changes that reduce friction in the member journey.


  • Conversational AI and automation assist the agent by automating the workflow, providing in-call alerts and guidance, and predicting the next best action based on real-time analysis of customer emotion, sentiment, and intent.
  • Post-interaction analysis of every conversation can detect member and agent-centric patterns across voice, email, text, or chat to identify trends such as the volume of calls that are related to claim denials or eligibility.
  • By analyzing 100% of conversations, payers can see which pain points occur most often and make adjustments accordingly to further reduce friction in the member journey


  • Improves time to resolution and reduces average handle time.
  • Improves member and agent satisfaction.
  • Increases agent productivity.
  • Provides valuable insight into trends and pain points for data-driven decision making and improvements.

Member experience translates into billons of dollars for Medicare advantage plans

According to McKinsey, Medicare Advantage is the fastest-growing line of business for many health plans. Yet, those plans have been leaving an estimated $2.9 billion on the table in Stars-related payments by not optimizing the member experience2.

Stars is the Centers for Medicare & Medicaid Services (CMS) quality assessment program. Plans awarded 4 or more Stars earn a 5% bonus on CMS payment benchmarks, as well as higher rebates to use toward supplemental benefits for members.  McKinsey estimates that Medicare Advantage plans in aggregate received approximately $12.2 billion in Stars-related payments in 2020.

However, there’s a change coming. A May 2020 rule from CMS indicates that customer experience metrics will begin to carry more weight in determining plans’ Star ratings. Instead of customer experience being around 32% of the total weight for 2020 ratings, the rule will see it increase to around 57% of the weight in 2023

Automate After-Call Work

What happens after the call ends can be just as important to your contact center’s business outcomes as what happens during the conversation. The time spent in after-call work (ACW) — including categorizing and summarizing the call, updating systems, and taking follow-up actions on promises made during the interaction — impacts average handle time, call waiting times, member satisfaction, costs, agent productivity, and agent satisfaction. Insurers can use conversational AI and automation to automatically handle ACW to achieve a remarkable return on investment.


  • Agents spend valuable time on labor-intensive, manual tasks after the call.
  • Because they are focused on performing tasks for ACW during the call, agents can’t focus on the conversation with the member.
  • Longer average handling time (AHT) increases wait times for other members.


  • Enables the experience during the call to remain conversational.
  • Lets agents focus their attention on delivering a caring, empathetic experience.
  • Increases accuracy of call summaries and categorization.
  • Improves agent efficiency and productivity.
  • Shortens AHT and reduces wait times.


  • Improves time to resolution and reduces average handle time.
  • Improves member and agent satisfaction.
  • Increases agent productivity.
  • Provides valuable insight into trends and pain points for data-driven decision making and improvements.

Detect Overpayment Before It Happens

Beyond automating activities and tasks that humans routinely perform, conversational AI and automation can be deployed to perform tasks that humans cannot, such as analyzing millions of calls to detect patterns or analyzing every interaction to enable identification of potential overpayment before it happens.


  • Overpayments and recovery expenses can cost payers hundreds of millions of dollars.
  • Recovery of overpayments (clawbacks) can damage relationships with providers.
  • Manually monitoring millions of call records to extract data needed to prevent overpayment is not humanly feasible.


  • Conversational AI and NLP can generate a transcript for interactions and then extract the relevant information to create a pseudo health plan and estimated medical claim
  • The estimated claim can then be automatically compared with actual claims when they are submitted.
  • Potential overpayments are flagged automatically before payment is processed.


  • Catches overpayments before they happen.
  • Improves payment integrity and reduces recovery costs.
  • Delivers a positive provider experience.

Health insurer saves $6 million

A large health insurance company operates multiple contact centers with more than 1,000 agents that handle over one million calls annually. Call volumes were high because members were unable to find answers using self-service. After-call work was taking too much valuable agent time after the call and prevented the agent from participating fully in the conversation with the member.

After adopting Uniphore U-Self Serve and U-Assist for intelligent self-service and in-call agent assistance and automation of agent after-call work, the health insurer achieved:

0 %

reduction in average handle time

0 %

reduction in after-call work time

0 %

reduction in new hires due to automation

$ 0 M

million in annual savings

Next steps

If poor member and agent experiences, lengthy wait times, long average handle times, agent productivity, scalability, staffing, costs, and other member experience problems are the symptoms, then conversational AI and automation are the antidotes for what ails payer contact centers.

The advanced  technologies described in the four use cases presented here are transforming the experience for members and agents. They’re enabling insurers to achieve measurable and sustainable business outcomes by delivering a positive,
frictionless experience for members and agents.

Take the next step and find out more about conversational AI and automation.

By clicking here, you agree that Uniphore may send you industry insights, service updates, and other marketing communications. You can unsubscribe anytime. For more details, review our privacy policy.

  1. “American Customer Satisfaction Index’s (ACSI) Finance, Insurance, and Health Care Report 2019-2020”
    American Customer Satisfaction Index, November 2020
  2. “New Stars Ratings for Medicare Advantage Prioritize Customer Experiences”
    McKinsey & Company, October 2020

Unleash the full potential of your voice and screen recordings

Table of Contents