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CASE STUDY
Transforming Service Experience
Leading Health Insurance Provider

CaseStudy
Monday, March 21, 2022

Transforming Service Experience for a Leading Health Insurance Provider

Transforming Service Experience for a Leading Health Insurance Provider

Our client is one of the largest health insurance companies in the United States with approximately 43 million members nationwide. They are dedicated to delivering better care, providing greater value and helping improve the health of our communities to their Members.

Transforming Service Experience for a Leading Health Insurance Provider

Key Initiatives Include

FROM CALL CENTER TO CONTACT CENTER

Driving personalized, predictive, prescriptive and proactive service insights to all channels (omnichannel) will deliver more digital options and digital “touches” for Member and Provider inquiries.

DIGITAL TRANSFORMATION OF CONTACT CENTER

Adding self-service (e.g. chatbots) and proactive notifications and alerts via apps and portals that can address service inquiries and more.

PERSONALIZED CUSTOMER SERVICE

Improves numerous key performance indicators (KPIs) including lower costs, improved handling times, call deflection, and higher Member, Provider and Agent satisfaction scores.

The Challenge

Our client faces business and technology challenges in their efforts to transform Member and Provider contact center experiences. They are confronted with large call volumes, long handling times and the additional costs associated with these calls.

Claims or Explanation of Benefit (EOB) calls, for example, can average 10-20 minutes depending on the caller type (different types of Members and Providers). Our client fields millions of these complex calls per year at great cost. Additionally, metrics like satisfaction scores, star ratings, and retention rates are negatively impacted if customer service is not optimal. Initiatives designed to lower call volumes and handling times can be challenged to improve Contact Center metrics like average handling time (AHT) or first-call resolution (FCR).

Call deflection (avoiding calls entirely) requires additional channels like self-service (e.g. chatbots) and proactive messaging (service interventions via app or portal notifications). Adding these service inquiry channels can be challenging to implement and optimize without specific, personal Member-specific insights that will address inquiries that otherwise would have been phone calls.

The Solution

This enterprise AI solution is continuously learning, evolving and adapting to meet your service experience needs. Our agent-assist solution greatly improves the speed and accuracy of customer calls by integrating Member predictions and insights into our client’s call center systems (CRMs).

Our Profile-of-One capability is helping our health insurance client build out customer profiles based on Member, Provider, Claims, and Benefits data as well as the rules, accumulators (for deductible balance), and claim and EOB reason code information that help resolve inquiries. The platform can then support the use of predictive models and rules engines attached to these profiles to drive the personalized, predictive insights that further drive business value.

This Customer Service agent-assist solution greatly improves the speed and accuracy of customer calls by integrating Member predictions and insights into our client’s call center systems (CRMs). These same insights are in the process of being integrated into self-service applications (e.g. chatbots) and proactive service interventions (e.g. Member app notifications).

Business Impact

CognitiveScale’s solution results in cost savings, lower handling time, better call resolution, and reduced call volume through self-service channels. Impact on KPIs include

  • ›  Improved First-Call Resolution (FCR) by 8%
  • ›  Reduced Average Handle Time (AHT) by 15%
  • ›  Annual cost savings total$11M
  • ›  Goal: 10% Call Deflection / Avoidance

CognitiveScale’s Customer Service solution is expanding from Commercial Member Claim Inquiries for Agent-Assist and Self-Service channels into other areas

  • ›  Provider Claim Inquiries
  • ›  Government Members
  • ›  Additional Self-Service & Service Intervention Channels
  • ›  Additional Inquiry Types (e.g. Benefit Inquiries)

Conclusion

CognitiveScale offers a wide range of solution offerings powered by our Cortex platform. We deploy Enterprise AI that is scalable across the entire organization. Our flexible platform allows organizations to infuse intelligence into business processes across the enterprise. Organizations can leverage pre-built solutions to rapidly deploy impactful AI, or leverage our low-code Cortex platform to build AI applications that solve any business problem. Contact us to explore how we can help your organization rapidly productionalize intelligence that helps you delight your customers and produce incredible business outcomes.

Contact us at sales@cognitivescale.com or 1-855-505-5001 to discuss how we can help you achieve incredible business results with our platform in your organization!

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