How Can Payers Improve Member Experience and Efficiency at the Same Time?

How Can Payers Improve Member Experience and Efficiency at the Same Time?

6 min read
The adoption of digital healthcare skyrocketed during the pandemic, exposing both persistent issues for payers as well as opportunities. The more healthcare consumers become comfortable with digital channels, the higher their expectations are for the same level of convenience, selection, and service they receive in other areas of their lives. This means that the more than 900 payers1 in the current U.S. healthcare market must continue to transform how they interact with consumers if they want to succeed. This is especially true given the increasing competition from more technology-savvy competitors and disruptive market entrants from non-healthcare sectors such as retail. Yet, many payers are still struggling to eliminate the friction in patient/member journeys, improve consumer satisfaction and loyalty, and driver greater efficiency. That’s where conversational artificial intelligence (AI) and automation can help.

Scoring an “Ok” Satisfaction Rating Isn’t Enough

Contact centers are the main touchpoints with members, greatly impacting overall member satisfaction. In fact, more than four out of ten members (43%) report that they prefer the call center as the primary channel for communicating about their health plan. More than half also say they want service representatives to have their information upfront when calling and 71% of members say shorter contact center hold times would improve their engagement with health plans.2. A Forrester poll of members of 17 of the largest health plans in the country found an industry average score of 70.2 on a 100-point scale for customer satisfaction, which Forrester categorizes as an “OK” rating. What’s the key to driving improved customer satisfaction? Out of six categories included by Forrester, customer service is the number one driver.3 Diving a little deeper into the data, drivers relating to how well customer service agents solve problems have the most impact on an insurer’s overall customer experience score. The authors of the report state that “sadly, brands failed to excel in this area. Nearly half of brands fell below the industry average in this category, pinpointing an anchor that’s weighing down the industry as a whole.”4

Members Have the Most Positive Experiences with Video Chat

A Forrester study found that video chat is the most emotionally successful communications channel for health plans, with

68% of members reporting a positive experience.

Source: “United Healthcare, Humana Top Healthcare Satisfaction Ratings,” Nathan Eddy, Healthcare Finance, September 2021

Understanding Customer Service Challenges for U.S. Payers

For payers, new challenges that arose during the pandemic — the pivot to work-from-home, acceleration of digital healthcare adoption, and worsening staffing shortages, to name a few — exacerbated many of the “pre-existing conditions” that already impacted the experience for both healthcare consumers and customer service agents.

Today healthcare organizations continue to struggle with:

Member dissatisfaction
The dynamic nature of the COVID-19 pandemic added to patient worries and uncertainties about their health, healthcare, and benefits. Combined with long wait times for assistance, high amounts of effort to get issues resolved and questions answered, and a lack of empathy and understanding on the part of stressed agents, member experiences aren’t living up to their expectations for an easy, convenient, and empathetic interaction.

Lack of scalability
Call volumes skyrocketed during the pandemic at the same time contact center employees had to shift to work-from-home models. Consumers faced long wait times to reach an agent. Even now, ongoing staffing challenges keep contact centers from being able to handle calls in a timely way while being empathetic to consumers seeking resolution to their questions and problems.

Operational inefficiencies
The more time agents must spend on manual, repetitive tasks such as after-call work (ACW), the less available they are to help the next member. Agents often have to log into and access multiple systems to execute workflows, impacting their productivity and wait times for other customers.

Poor agent experience
Handling frustrated members in a challenging work-from-home environment led to increased agent stress and overload as call volume soared during the pandemic. As pandemic restrictions lift, healthcare contact centers must continue adapting their operating models, workforce management, and agent technology to support the hybrid workplace and improve the agent experience no matter where the agent is working.

High claims costs
For payers, overpayment of claims and recovery costs can inflict millions of dollars in losses. Recovery of overpayments (clawbacks) can also damage relationships with providers. Yet, the information payers could use to prevent overpayment before it happens remains unavailable because it’s contained in unstructured voice data from conversations with patients and providers.

Conversational AI and Automation Optimize Experiences and Reduce Costs

Optimizing the member experience starts by understanding and optimizing every conversation before, during, and after an agent/consumer interaction — from self-service to agent assistance to after-call follow-up and post-interaction analytics.

That’s where conversational AI is making a tremendous impact on helping payer contact centers address the challenges they face to drive improvements in member satisfaction, customer experience index scores, operational efficiency, and other strategic metrics.

Conversational AI is a set of advanced technologies that recognizes and comprehends human language and uses this understanding to optimize, automate, and analyze conversations in and across multiple channels. With a conversational automation platform powered by AI, payer contact centers can use machines to automate conversations and augment agents, including:

Conversational self-service

Automate common, repetitive inquiries with personalized self-service via an omnichannel intelligent virtual assistant (IVA), supporting voice, web, and mobile channels, to offload interactions while accelerating resolution. An IVA with conversational AI passes the context from an IVA to the contact center to create a frictionless experience for patients or members who need further assistance.

In-call guidance

Conversational AI optimizes every conversation by enabling agents to be more productive and empathetic while personalizing the experience for members. By using conversational AI to understand the consumer’s real intent and sentiment, contact centers can help agents deliver a more conversational experience while resolving issues faster.

Automated after-call work

Automating ACW improves accuracy and productivity as well as enhances the consumer’s and the agent’s experience.

Post-interaction analytics

Automate post-interaction analytics on 100% of contact center conversations to gain deep insight into trends and opportunities for improving member satisfaction and operational efficiency. Automated analysis detects patterns across voice, email, text, or chat to identify trends such as the volume of calls that are related to claim denials, billing, or eligibility

A colorful heartbeat logo with orange and pink hues set against a sleek black backdrop.

AI Adoption in Healthcare


of healthcare organizations have an AI strategy in place


of healthcare execs rank improving patient experiences as the greatest impact of their investment in AI

Source: “3rd Annual Optum Survey on AI in Health Care,” Optum, October 2020

Delivering Better Member Experiences With AI

One of the largest Medicaid managed care organizations serving more than five million members in 13 states and the District of Columbia needed to simplify and automate its contact center operations to deliver a better experience and drive better health outcomes for members.

The managed care organization adopted the Uniphore Conversational Automation platform for its real-time agent assistance and automation solutions. With Uniphore, the organization can now provide its agents with real-time guidance including next best actions, best practices, and compliance as well as automation for ACW and call dispositioning. With the right context and member information at their fingertips, agents make members aware of gaps in care and recommend actions that improve health outcomes.


20% reduction in agent training time

60 second reduction in average handle time (AHT)

Improved member satisfaction

Better health outcomes


The changes affecting the U.S. healthcare market continue to pick up pace, even as the impact of the pandemic begins to lessen. Consumers are raising their expectations more every day. They seek out payers that deliver the type of convenient, fast, and empathetic experiences they’ve come to expect from other sectors.

Conversational AI and automation address many of today’s ailments in the patient/member journey while improving efficiency and reducing operational costs at the same time. Choosing the right conversational automation platform that addresses the entire member conversation from self-service to post-interaction analytics can help your organization deliver a positive, frictionless experience for your members.

1 – “Administrative Simplification: How to Save a Quarter-Trillion Dollars in US Healthcare” McKinsey & Company, October 2021
2 – “Digital Member Experience Services May Boost Plan Satisfaction” Victoria Bailey, HealthPayerIntelligence, September 2021
3 – “Forrester: These Are the Payers With the Best Customer Experience”, Paige Minemyer, Fierce Healthcare, September 2021
4 – Ibid

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