Call Centers Effectively Used in the Insurance Industry

In the insurance industry, only about 20% of the calls received cannot be handled by a call center using a effective database system and well trained personnel.  The 20% that cannot be handled by the call center, either during business hours or “after hours” typically surround the specifics of a claim and a claim analyst would need to respond to the member directly.

However, most calls are routine in nature and we have listed the most common calls received by a call center in the medical insurance industry below:

1. Did you receive my claim?
2. What is the status of my claim?
3. Did you receive my enrollment paperwork (for my new born for example)?
4. What is my deductible / how much of my deductible have I satisfied?
5. I need to find a doctor or specialist in network, and I need to schedule an appointment
6. Why was this charge not paid or denied?
7. I have an emergency.
8. Is “xyz” covered?
9. Calling in to provide information the insurance company has requested of the insured.
10. The need to add or cancel existing coverage.

Looking at the calls above, even an untrained call center staff that does not specialize in health insurance, and taking calls “after hours” should be able to address 60% of these calls to completion, assuming the database system they are working from is state of the art and communicates with the claim system back at the claim processing center.  Today’s systems available to the call center should show the call center associate when a particular claim has been received and even provide detail such as “in process” or “complete.”  In most cases, the insured will be satisfied just knowing the insurer has received the claim, and learning the claim is “in process” is enough for them to have a positive experience with the insurer.

Basic questions about the particulars of the medical plan, again should be available to the call center employee.  Once a member is located on the screen using social security number, member ID number, or last name, the database should show the particulars of the plan in which the member participates:  deductible, coinsurance, plan enrolled in, details of what is covered, exclusions, etc. 

If the member has an emergency, the insured will be instructed in most cases to call 9-1-1, but the call center can perform pre-admission certification if there is time, and if “after hours” they still can collect enough information so the claim team can begin working on the case when they arrive in the morning.  For example, the claim team can contact the hospital and set up direct billing.

Of the list above, number 6 and number 10 would pose the largest problem for an “after hours” call center.  Telling an insured exactly why a claim was denied may require the actual claim analyst that worked on the claim, unless the reason for the denial was posted in the system and the call center employee could read the information to the employee or interpret a list of symbols that are often associated with claim denials.  In this case the most common area where the call center could keep the process moving forward, would be when the insured did not provide enough information for the claim to be process to completion.  In this case the call center can tell the insured what information was not provided, and even collect the needed information.

Finally, most call centers are not able to add entirely new lines of insurance coverage, like adding a dental program to accompany an existing medical plan.  However, in most of these cases the call center can provide the employee with the proper paperwork and again, keep things moving forward. 

In summary, a good call center with the right technology is extremely important in the insurance industry, and for good customer service in this industry, the call center should be an area that receives significant investment.