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

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Overview

Enabling true self-serve for health insurance customers requiring medical pre-authorisation. Upgrading to automated conversational process from a manual process managed via call centres with customers calling for total support or agents calling customers for clarification over incomplete or unclear requests captured through web forms.

The company at a glance:

Use case

Pre-Authorisation

50+

Years of trading

>1.5k

Employees

>0.5M

Policyholders

>1M

Providers network

Challenge

With headquarters in the UK but operating all around the world, the provider of medical insurance has to manage more than 1 thousand interactions per day the majority of which related to customers requesting for pre-authorisation 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 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 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 teamed up with Spixii leveraging its insurance and process automation expertise.

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 client designed the the customer journey which is also the business process. 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.

By doing so, the new process took the form of a powerful conversational self-serve, or, in other words, an online and structured conversation with a 24/7 available expert chatbot. The processing time was reduced 20 folds from 34 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, even lasting hours with no session expiring,  no line being unexpectedly cut or no agent having to end the conversation: they could respond at their time with no rush. All of this at no extra cost to the client.

Artboard – 23

Available through desktop and mobile applications, more than 40% of all interactions resulted in 100% automated decisions, a number that can only grow as more symptoms and treatments will be categorized and included in the automation process. In comparison, the remaining 60% resulted in high data capture saving a considerable amount of time for human processing.

With an average of a couple of hundreds of requests solved per day, the chatbot produces more than 60 uninterrupted working man-hours per day or more than 900 days per year.

Being 24/7 available, the new process serves 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 new process actually augments and adds valuable resilience to existing call centres.

The automation of the operational tasks was tested and approved by the relevant business unit, giving total confidence in the repeatability of the automation.

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 the 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:

200

average requests solved per day

40%

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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