By Zaffar Khan

The idea of helping health plans increase member enrollment in health risk adjustment programs that improve health outcomes, care coordination, and quality of life is nothing new.

But the way it can be accomplished today is. 

GenAI voice agents, or Agentic AI, are poised to relieve call center agents of repetitive tasks easily handled by the technology. GenAI can help improve functions and processes critical to health plan success.

These are a few key areas where GenAI voice agents can contribute to health plan success:
  

• Improved reimbursement by CMS: CMS uses risk adjustment models to determine how much to pay health plans for each member. 

• Better manage member health: With a better understanding of their members’ health risks, health plans can develop programs and interventions to improve their health and lower costs. 

• Improve Star Ratings: Star Ratings are a quality rating system used by CMS to evaluate Medicare Advantage plans. Plans with higher Star Ratings can earn bonus payments and attract more members. 

• Better negotiate with providers: Health plans can use their risk adjustment data to negotiate better rates with providers.
  
  

There will be occasions, undoubtedly, when the member doesn’t have the time to talk or would rather not talk to GenAI voice agents, though as discussed earlier, many of us can’t tell the difference between the technology and a human speaker. Nevertheless, if this occurs, the solution will generate a text and send it to the member along with a secured portal link with all the needed information security and privacy guard rails to fill out the HRA online. For those who choose not to engage with a GenAI voice and are not interested in using a portal link, there is an option to speak directly with a live agent.

Operational, Business Benefits for Payer-to-Payer Interactions 

A GenAI voice agent supports payer-to-member communications; it can do the same for payer-to-payer communication in several important ways. Confirming member coverage is a time-consuming, arduous task. Every health plan, however, weathers the process. With the assistance of a GenAI voice agent, however, health plans can shift much of this work to this emerging, powerful technology. 

The voice GenAI agent can make outbound calls to other payer organizations to collect the member’s eligibility details for primacy coverage determination, which enables the coordination of benefits between payers. 

In addition, a GenAI voice agent supports efficient claims processing through the automation of routine tasks like claims verification, eligibility checks, and prior authorization requests. This reduces processing time and mitigates costly errors. 

The technology can help payers improve:

• accounts receivable and accounts payable

• cash flow

• incorrect denial of claims

• rework

• appeals 

• potential late claims, interest, and penalties

• provider abrasion

• member experience
  
  

This class of automation can lead to significant cost savings by reducing labor expenses and improving operational efficiency. 

Enhancing Relationships: Payers, Providers, Members

The GenAI voice agent can help build and maintain relationships among payers, providers, and members. By absorbing several health plan challenges, GenAI voice agents free up staff for more strategic, fulfilling activities within the business. 

A GenAI voice agent approach ensures member information is captured and acted upon by the health plan and the member’s care coordinators, caregivers, and providers. Across the board, the technology promises to help advance healthcare in 2025 and beyond as an easily scalable solution to handle ever-increasing call volumes and growing member populations.

Zaffar Khan is Associate Vice President of Business Transformation & Generative AI Solutions at Sagility.

This article originally appeared in Healthcare Contact Center Times.