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Large International Health Provider delivers immediate decisions for worldwide pre-authorisations of medical claims.

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Overview

The customer service operations increased its resilience and productivity by equipping their digital channel with a true self-service for their health insurance customers requiring pre-authorisation of medical claims. The new automated conversational process offers a powerful alternative to phone calls and emails that is quicker than 20 times when requests are fully automated and more than twice when not, thanks to better data captured.

The company at a glance:

Use case

Pre-Authorisation of Claims

50+

Years of trading

>1.5k

Employees

>0.5M

Policyholders

>1M

Providers network

Challenge

With headquarters in the UK and operating all around the world, the health insurer has to manage more than 1 thousand interactions per day. The majority of which relate to customers requesting pre-authorisation for medical claims i.e. asking if their next appointment will be covered by their policy and paid for in advance by the insurer.

Such inbound interactions are usually managed through the phone, emails and online web forms. In order to deal with these enquiries, and before communicating to the customers if the appointment will be covered or not, the skilled customer service agents have to gather detailed information, translate it into business language and check it with the internal decision engine. Having to manually categorise several hundred symptoms and treatments, the process is often very complicated, time-consuming and requires well-trained agents to execute it. For example, when carried out over the phone, this process takes on average 17 minutes for the agent and 17 minutes for the customer, so 34 minutes total. On top of this, the customer has also to wait to be connected to an agent.

Sometimes the decision can’t be made immediately, and when communicating via emails, the process can take up to 3 working days.

medical pre-auth2

Solution

As part of its core strategy to be closer to the customer and to deliver its high-value services digitally, the client chose the Spixii Conversational Process Automation platform for its expertise to integrate to core systems and build business processes in a conversational way that can deliver end-to-end automated.

Automating the pre-authorisation process is very challenging due to the high number of possible combinations of symptoms and treatments, explaining why it is usually executed over the phone with the support of expert agents going through all the steps. Digitally speaking, the previously adopted web forms were simply capturing free text input from customers, and the questions were too generic to power any process automation, let alone be
user-centric when using a mobile.

Leveraging the Spixii Conversational Process Automation platform, the insurers designed the new customer journey with their business knowledge. In the Spixii platform the journey and the business process are one. In other words, the operational tasks that the skilled agents would perform started to be automatically triggered by business logic depending on the positioning of the customer in the journey.

The new process took the form of a powerful conversational self-service which a business process executed by a chatbot available 24/7. Exceeding expectations, the processing time was reduced 20 folds from 40 minutes to 2 minutes (0 for the agent and 2 minutes for the customer). At the same time, vulnerable customers could benefit from longer conversations and no line being unexpectedly cut or no agent having to end the conversation: they could respond at their time with no rush.

Artboard – 23

Available through desktop and mobile applications, more than 45% of all interactions resulted in 100% automated decisions, a number that can only grow as more symptoms and treatments will be better categorised. In comparison, the remaining 55% resulted in better data capture saving a considerable amount of time for manual processing.

With more than a couple of hundreds of requests received per day, the self-service produces more than 60 uninterrupted working man-hours per day or more than 900 days per year. This has a significant impact for the resilience of the customer service operations.

Being 24/7 available, the new process deals with requests as they come and can handle a virtually unlimited number of conversations at the same time and protect customers that get in touch out of working hours when call centres may not be available.

The automation of the operational tasks was tested and approved by the relevant stakeholders, giving total confidence in the repeatability and consistency of the automation of this high-value process.

In addition to the digital, operations and IT applications teams, the data and analytics team of the client also has access to the Spixii platform to crunch the valuable data and identify future improvements with the ultimate goal of increasing the automation ratio.

Results at a glance

From day one after the go-live date the new conversational experience started to generate stellar results:

220

average requests solved per day

45%

of total interactions is fully automated

20x

faster interaction from 40 to 2 minutes

60+

uninterrupted working man-hours per day generated
robot with outstretched hand

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