From Efficiency To Growth In Health Insurer Contact Centers

How practical modernization reduces friction, lowers operating costs, and boosts satisfaction and retention for members and clinicians.

Howard Lapsley, Vladislav Gil, Marc Rousset, Ethan Murray, and Corey Rochkin

5 min read

Welcome to the new dawn of the contact center.

This is not just about answering calls faster or allocating those calls more effectively to self-service or to senior reps with specific claims expertise. Health insurers — and all ancillary carriers — need to think of their contact center as a lighthouse: it not only saves ships during operational storms by illuminating rocky shores to avoid customer service and cost efficiency mishaps but also acts as a key navigational aid to elevate stakeholder satisfaction, engagement, and retention, lower total costs of care, and drive overall business growth. The contact center is the most prominent touchpoint for member and clinician engagement. Yet industry benchmarks tell a mixed story when it comes to customer satisfaction. The American Customer Satisfaction Index in 2024 reported that contact center satisfaction was 76 on a 100-point scale. While solid, the score suggests that members encounter friction when interacting with contact centers. And contact center satisfaction trailed access to specialists and prescription drug coverage, two areas that are typically cited as major pain points.

Physicians and care teams express even more frustration with insurers’ customer service, rating it 1.84 out of 5 in one survey; communication from payers rated poorly at 2.03 out of 5. While these ratings encompass more than the contact center, they are a glimpse into the angst that clinicians feel in navigating the maze of claims, appeals, prior authorizations, and care coordination.

The exhibit below illustrates how and why members and clinicians experience pain points. Calls that are not contained or resolved effectively lead to repeat calls. That, in turn, adds costs and impacts satisfaction. Bad experiences drive churn and most originate with issues previously raised and left unresolved with contact centers, even if the root cause is elsewhere in the organization. Fixing friction points not only lowers operational costs, but improves satisfaction, leads to higher retention, lowers total costs of care, and improves Star ratings for Medicare Advantage Plans.

Exhibit 1: Mapping the call lifecycle

The latest artificial intelligence (AI) tools empower insurers to comprehensively map each individual call, diagnose the root causes triggering the calls, identify the frequency of repeat calls, and uncover the obstacles preventing their resolution.

High performing organizations recognize that every interaction with members or clinicians is critical, whether it’s a retention effort, care intervention, or routine customer service call. The good news is that retooling a contact center doesn’t take a dramatic overhaul. It comes down to practical modernization — combining technologies, including various forms of AI, with shifts to the staffing and coverage model to make longstanding business processes work smarter, faster, and at a lower cost.

The New Reality: Practical Strategies that Deliver

Imagine a contact center where repeat callers — often 20% or more of total volume — have the root cause of their problem identified and addressed immediately, eliminating duplication of work and unnecessary delays for callers. To achieve this, insurers need to understand why members and providers are calling and what in the organization is failing that is causing their issue. Traditionally, this was not an easy task as insurers could only analyze a small percentage of calls to detect problem areas. Now, by deploying AI, companies can rapidly analyze 100% of past call transcripts to identify reasons for calls, complexity of the issue and how easy it was to address, and value to callers and the insurer if they are addressed more efficiently.

Exhibit 2: Call transaction types

We often find that many calls are transactional in nature, ideal candidates for automation, and more broadly a signal of issues in other systems that are forcing calls. Modern AI-enabled systems can even assist with knowledge-based inquiries, eliminating the need for callers to wait for an agent.

From there, organizations can develop actionable strategies to deliver process improvement, not just faster answers. By AI-powered analysis of transcripts, targeted member outreach, service, and clinical triage could be seamlessly integrated with sales, marketing, and provider management, ensuring that every touchpoint adds value and reduces downstream cost. On the provider side, integrating clinical expertise, smart segmentation, and proactive support will hasten claims or authorization processes, resulting in higher provider net promoter score and better system-wide engagement.

Unlocking the power of people and technology

While there are a host of tactics insurers can take to improve contact center performance, we’ve zeroed in on seven approaches that companies should act on now:

AI-powered routing to ensure that every caller — whether a member or a provider — enjoys the fastest path to resolution, effectively eliminating the frustrating experience of being rerouted multiple times
Dynamic call segmentation and agent tiering to ensure calls are handled in the right channel and agent based on call complexity and relative call value
Sophisticated self-service with integrated authentication to allow callers to quickly get common issues addressed and provide agents with context of a call before they even connect with the caller
Empowering front-line teams with clinical voice assistants to accurately direct patients to the most appropriate care settings reduces unnecessary emergency department visits and supports better clinical outcomes
AI-powered agent tools that provide real-time guidance on how to respond to callers, improving experience or yielding insights to drive interventions, all leading to lowering of total costs of care
Agent compensation and development models that are tied to performance and incentivize retention
Systematic analysis of contact center data and transcripts to continuously identify opportunities to reduce repeat contacts and enhance overall customer experience both within the contact center and across the organization

Exhibit 3: Anatomy of the call

AI analytics provide scalable insights into how time is spent during calls, eliminating the need for staff to listen in. These tools can identify pain points, such as excessive time spent authenticating callers or extended waits as agents manually enter information.

Making the contact center an engine of growth and profitability

The business case for making these changes is compelling. We’ve seen transformations lead to significant performance improvements, including a 40% reduction in calls, a 20% decline in call time, and a 40% reduction in operating costs. And this isn’t even counting the benefits from creating improved customer experience, engagement and retention that will reduce total costs of care and improve provider interactions and interventions

Smart leaders leverage their contact center as a source of growth. Making that transition requires a shift in mindset and leveraging technology and people. It’s no longer just about staying afloat. It’s about setting a course for lasting success.

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