Payer Archives - Sagility Health

Handling Engagement Spikes Effectively Amid Surging ACA Premiums

Posted on February 16, 2026March 5, 2026 by Arun Sharma

Michael LeVangie, Senior Vice President

The health insurance open-enrollment period is known to be a notoriously stressful time for payers and members alike. In 2026, health plans nationwide are facing historically high call volumes amidst surging ACA premiums and general volatility in the individual marketplace, stemming from the passage of the OBBBA in July 2025. Case in point is Michigan, where Blue Cross Blue Shield of Michigan (BCBSM) has seen its marketplace call center volumes surge by 20% due to unprecedented ACA premium spikes and the expiration of enhanced subsidies. Michigan’s surge is a microcosm of what’s happening nationwide. BCBSM has already exceeded 10,000 marketplace-related calls and tripled call center staffing to more than 100 individuals to keep up. Expected marketplace customers for 2026 may reach over 310,000.

Healthcare Pressures Are Fueling Member Confusion Everywhere

This challenge, however, is not unique to Michigan. Across the country, rising premiums, shrinking subsidies, and massive enrollment churn are creating operational strain for health plans of every size. ACA premium increases are contributing to a surge in consumer confusion and service volume. Fitch Ratings reports widespread ACA marketplace disruption across the U.S., driving risk pool deterioration and insurer reevaluations.

When premiums spike and subsidies shrink, health plan demand surges. These cost spikes are driving unprecedented consumer confusion — and confusion drives calls. Mitigating the surges and their associated costs is possible with immediate and extended strategies. A combination of short- and longer-term structural strategies ensures the most complete solution — one focused on member behavior, workflow optimization, and technology intervention, not just staffing levels.

Immediate Strategies to Mitigate the Effects from the Surge in Volume

Sagility’s short-term surge strategy combines people-powered expertise with rapid digital support to stabilize operations fast. We immediately deploy staff with deep knowledge and training to deal with surges to prevent errors and repeat calls. These tactical fixes handle the escalations related to disruptions and regulatory changes with or without permanent staff. Some specific remedies include: term surge strategy combines people-powered expertise with rapid digital support to stabilize operations fast. We immediately deploy

Elastic staffing model: We maintain a pool of staff who already understand payer operations, including terminology and regulatory guardrails. These cross-trained individuals can ramp rapidly across geographies, so payers do not carry FTEs annually. Intraday management with rapid reforecasting including AI-assisted forecasting, can rebalance staffing hour by hour. For enrollment deadlines and renewal cycles, we implement extended hours.
Rapid micro training on surge intents: Sagility’s domain experts can deliver short, targeted refreshers: new benefit year changes, prior authorization updates, PCP/network changes, state-level coverage updates, and common misstatements to avoid. This micro-training helps to prevent repeat calls and compliance risks during spikes.
Tiered routing: Organizing call flows so that each call reaches the right “tier” ensure that calls reach the right level of expertise the first time, including routing “deflection-friendly” intents to self-service channels before hitting live reps. Tier 1 handles high-volume “how do I…” and status calls. Tiers 2 and 3 handle more complex eligibility, tax-credit questions, and escalations. volume “how do I…” and status calls
AI-Powered short-term digital relief: Digital entry points to absorb a large share of repetitive, high-volume intents, which can reduce live traffic by 15–35% volume intents
- Interactive voice response tuning: Adjustments can address top healthcare intents and add surge-specific options, such as, “Press 2 for billing changes.”
- AI targeting: Sagility pairs Agent Assist with humans for high-volume, low-risk intents. Virtual agents handle top intents. Fewer calls reach humans, and the calls that do reach humans are shorter and better prepared — reducing abandonment drivers.

These short-term actions ensure fast stabilization, lower abandonment rates, and consistent, accurate communication during spikes. Short-term remedies deliver expanded capacity, the ability to maintain SLA performance, and the ability to contain the surge.

Longer-Term Strategies: How Sagility Uses AI to Contain and Prevent Spikes Term Strategies

As healthcare organizations look beyond short-term surge response, real transformation comes from building an operating model that reduces call volumes at the source and prevents future spikes altogether. Sagility enables this shift by combining deep healthcare domain expertise with advanced AI and structural modernization — redesigning digital pathways, strengthening knowledge and compliance systems, optimizing workforce models, and predicting demand with far greater accuracy. term surge response, real transformation comes from building an operating model that reduces call volume at the source and prevents future spikes altogether. Sagility enables this shift by combining deep healthcare domain expertise with advanced AI and structural modernization

Modernizing and simplifying digital member pathways: The redesign of digital experiences across benefits, claims, eligibility, pharmacy, and prior authorization helps members self-resolve issues without calling. These tactics surface real-time information, embed AI explanations, streamline navigation, and improve mobile access to common questions, reducing the friction across digital journeys. resolve issues without calling. time information, embed AI explanations, streamline navigation, and improve mobile access
Strengthening knowledge, policy, and compliance systems: To ensure clarity and consistency across all channels, Sagility modernizes the entire knowledge ecosystem. We transform outdated SOPs into policy locked, AI-accessible guidance, along with explainability scripts for complex topics. Unified knowledge feeds chat, voice, and digital tools, and automatic updates reflect benefit changes, premium adjustments, or regulatory requirements — keeping every channel accurate and aligned. locked, AI accessible guidance,
Identifying and preventing spikes: AI and analytics help us identify issues early and prevent call spikes before they occur. Anomaly detection highlights problematic issues in real time, while predictive models forecast volume by intent. Automated, trigger‑based outreach helps preempt member confusion, and real‑time dashboards continuously monitor friction points across digital channels and the contact center to enable fast intervention.
Creating high-trust self-service with intelligent automation: Sagility builds intelligent self-service tools that reliably address high-volume needs. Virtual agents handle common claims, benefits, PA, pharmacy, and provider inquiries; automated workflows simplify routine actions; and machine learning improves accuracy over time—building trust in digital channels and reducing reliance on live support. service tools that reliably address high volume needs. Virtual agents handle common claims, benefits, PA, pharmacy, and provider inquiries; automated workflows simplify routine actions; and machine learning improves accuracy over time—building trust in digital channels and reducing

The combination of short- and long-term strategies creates a resilient, digitally enabled ecosystem to anticipate member needs, instill trust in self-service alternatives, and resolves operational complexity upstream — resulting in sustainably lower call volumes, improved member experiences, a more stable, efficient service environment, and more predictable operating costs because the system is built to handle complexity before it ever reaches a contact center. Sagility is uniquely positioned to help provide the right blend of experienced staff, technology-led transformation to address extreme fluctuations in demand, and trusted collaboration to deliver the right set of solutions. term strategies create service

Resilience Over Perfection: A Healthcare Cybersecurity Roadmap for 2026

Posted on January 23, 2026January 28, 2026 by Arun Sharma

By Shwetank Verma, Global Chief Information Security Officer

In healthcare, cybersecurity is ultimately about protecting care. Every workflow — from bedside monitoring to revenue cycle operations — now depends on digital systems and a sprawling mesh of connected devices. In this reality, the most successful organizations adopt what at Sagility calls a mindset of resilience over perfection; acknowledge that attacks and disruptions will occur, then design people, process, and platforms to anticipate, withstand, and recover without compromising patient safety or operational continuity.

Why Resilience Beats the Myth of Perfect Security

Perimeter-only defenses and one-time hardening projects can’t keep pace with today’s threat landscape. Cloud workloads scale by the hour, clinicians and staff work everywhere, and the Internet of Medical Things (IoMT) introduces thousands of specialized endpoints with uneven patch cycles. Aiming for “no incidents” creates fragile security: one missed patch or misconfigured identity can unravel the entire stack. Resilience, by contrast, accepts uncertainty and invests in visibility, containment, and rapid recovery — capabilities that determine clinical impact.

Four Pillars of Resilient Healthcare Security

Identity is the new clinical perimeter: Compromised credentials remain the fastest path to ransomware and data exfiltration. Enforce Zero Trust principles with strong multi-factor authentication (MFA), least-privilege access, just-in-time elevation for admins, and continuous risk-based authentication. Pair identity and access management (IAM) with behavioral analytics to spot unusual lateral movement or impossible travel. The goal: if an account is abused, it is detected early and segmented before it becomes a worldwide outage.
Endpoint and IoMT Protection Must Be Lightweight and Automated: Clinical devices can’t tolerate heavy agents or frequent reboots. Favor cloud-delivered, AI-driven endpoint protection that inspects behavior rather than just signatures; coverage should extend to identity as well as the device itself. Automated isolation, one-click network containment, and policy-driven response are essential for resource-constrained healthcare teams. Modern platforms that secure “thousands of devices” with a lightweight, automated approach are uniquely suited to healthcare’s realities — particularly for hard-to-patch IoMT that proliferate in healthcare.
If No Environment Is Secure, Focus on the Ability to Control and Contain: Microsegment clinical networks; keep IoMT, admin, guest, and research traffic separate by default. Back up electronic health records (EHRs), imaging archives, and critical operational systems with immutable storage and regular, audited restores. Maintain application allow-lists and block egress where not required. If a malware incident occurs, it should be local and recoverable, not systemic.
Operational Readiness — Practice the Response You Intend To Execute: Tabletop exercises with clinical leaders, legal/compliance, and communications are nonnegotiable. Define role-based protocols that determine who will shut down a device fleet, who will speak to media, how to prioritize ICU vs. outpatient systems, and how to deliver manual “downtime” procedures safely. Measure mean time to detect (MTTD), contain (MTTC), and restore (MTTR) — the core KPIs of cyber resilience.

A Pragmatic Roadmap for Healthcare

Start With an Accurate View of the Enterprise: Map your assets — endpoints, IoMT, identities, SaaS, and third-party connections. Protection begins with what you can see. Use continuous discovery for unmanaged devices and shadow SaaS; reconcile with a configuration management database (CMDB), a central system of record that stores information about an organization’s IT assets and how they relate to one another. Document data vulnerability so that risk is based on reality, not inventory folklore.

Modernize Identity Controls Before Everything Else: Implement MFA for everyone. Employ phishing-resistant methods for privileged roles, and conditional access policies tuned to clinical workflows (e.g., location-aware rules for on-prem units). Instrument user and entity behavior analytics (UEBA) to catch session hijacking and service-account abuse.

Harden Endpoints and RightSize Controls for IoMT: In the case that devices can’t run full agents, deploy network-based segmentation and passive monitoring. Identify and assess new patches that align to healthcare environments requirements. Safely install approved patches as needed. When patching isn’t possible, compensate with strict network controls and application isolation.

Build “Golden Paths” for Rapid Recovery: Document the minimum viable set of systems to safely deliver care (EHR access, meds administration, labs, imaging). Align recovery time and point objective (RTO/RPO) targets to those dependencies. Test restores quarterly; verify that backups are offline/immutable and that credential vaults and identity provider (IdP) configurations can be rebuilt without the primary network.

Neutralize Third-Party Risk: From revenue cycle partners to specialty telehealth apps, third parties expand both capability and risk. Apply contractual security requirements, tokenized or minimized data shares, and event-level logging with independent alerting. If a partner is breached, you should know through your telemetry, not via an outside media channel.

Culture: The Resilience Multiplier

Incident-response protocols alone won’t carry a hospital through an incident at 3 a.m. Resilient programs invest in human factors: concise phishing simulations for clinicians, quick-reference downtime guides at workstations, and a blameless reporting culture that surfaces weak signals early. Security must be embedded in innovation cycles — from pilots of AI documentation tools to new patient-engagement apps — so that compliance, privacy, and engineering collaborate from the start.

Metrics That Matter to the Board

Move past vanity counts (blocked attacks) and focus on timebased and outcome-based measures:

Mean time to detect, contain, and recover
Percent of critical assets covered by endpoint detection and response (EDR)/identity controls
Incident‑response exercise and pass/fail criteria for restoration drills
Third-party telemetry coverage and SLA adherence. These data points relate directly to care continuity and financial resilience, making them meaningful for executives and regulators alike.

The Way Forward

Healthcare’s digital future is bright — and inherently complex. By embracing resilience over perfection, leaders can protect patients and preserve trust while still moving boldly toward AI-enabled, data-driven care. The blueprint is clear: identity-first security, lightweight automated protection across endpoints and IoMT, microsegmentation and recovery discipline, and relentless operational practice. That is how cyber programs evolve from fragile defenses into durable advantages — exactly the approach that Sagility takes partners with payers and providers to modernize healthcare with confidence.

Discover more about Building Cyber Resilience in the Age of Innovation, insights from 11 forward-thinking cyber leaders, including Shwetank Verma.

How Process Mining Ends Payer Operational Silos

Posted on January 20, 2026January 28, 2026 by Charlotte Robidoux

By Mitesh Kumar, Senior Vice President, Claims Practice Lead

In the complex ecosystem of modern healthcare, the term “silo” carries a costly connotation. While silos on a farm protect valuable grain, organizational silos in payer operations — specifically within the claims process — are actively destructive. These internal barriers force claims information to pass through a convoluted, multi-system journey, touched by numerous departments and people before finally being resolved. At best, this route is circuitous; at worst, it’s a disaster leading to errors, delays, and immense administrative waste.

The scale of this inefficiency is staggering. Payers process approximately 5 billion claims and deny 850 million claims every year. The current approach to managing this volume relies heavily on legacy systems and dashboards that only offer surface-level user metrics, highlighting existing problems like high pend rates and rework, but offering no real insights into why these issues persist. This failure to diagnose the root cause means the claim remains perpetually destined to bounce from one silo to the next, fueling frustration for providers, members, and internal staff alike.

Mapping the Complex Journey with Process Mining

Thankfully, a more intelligent and proactive solution exists in the form of progressive business process optimization (BPO), leveraging the power of process mining. Moving beyond traditional metrics, process mining provides a single, comprehensive, and real-time view of how a claim truly flows through an organization. By analyzing system data, this technology maps out the complex, end-to-end journey of every claim, clearly identifying precisely where, why, and what causes it to get stuck in the process.

This granular, data-driven visibility is revolutionary. For example, if a payer is struggling with a high rate of provider appeals — a factor that can negatively impact critical Star Ratings — a tech-led solution can use process mining to visualize the entire life cycle of an appealed claim. By mapping data upstream and downstream, a payer, working with experienced teams, can gain deep insights into the exact moment the claim was denied, the system responsible, and the underlying contractual or procedural error. This empowers the organization to improve the process at its source and significantly lower the number of unnecessary appeals. A major benefit of this tech-led solution is its ability to construct a detailed timeline and sequence of every activity, enabling payers to identify precise intervention opportunities that prevent similar issues from occurring in the future.

Breaking Down Silos: Immediate and Tangible Benefits

Process mining breaks down operational silos by using empirical system data to examine and locate specific areas for improvement, revealing how processes actually function, not how they are theoretically supposed to. By identifying hidden patterns and bottlenecks, organizations gain the necessary understanding to streamline workflows and permanently eliminate redundancies.

The removal of these operational silos delivers several immediate and tangible advantages that benefit all stakeholders:

Reduce provider abrasion: By streamlining claims processes and identifying critical touchpoints, payers dramatically improve communication and transparency with providers, strengthening crucial payer-provider relationships.
Fast turnaround times: Establishing process models pinpoints optimization opportunities, thereby accelerating the claims processing cycle. This faster resolution reduces abrasion and frustration for both members and providers.
Improve operational efficiency: The reduction in gaps, manual intervention, and redundancies creates significant reductions in administrative costs, fostering a leaner and more efficient operating environment.
Decrease late claim payment interest: By restructuring workflows to prevent avoidable delays and identifying bottlenecks, the necessity for late claim interest payouts — a costly administrative expense — is reduced substantially.

In summary, this efficient solution, buttressed by the input of dedicated operational experts, supports seamless information exchange and transparent communication with all parties. By strategically addressing the persistent and exceptional issues that plague the claims process, payers not only improve their internal operations but also drastically reduce provider abrasion and enhance the overall member experience — fostering improvements that represent the ultimate goal for everyone in the healthcare industry.