Creating Member-Centric Chatbots

It’s a common scenario. A patient’s doctor lays out a treatment plan, providing the steps necessary to improve their health. They feel hopeful, but then a wave of anxiety overcomes them. The question lingers: how much will this cost?

In today’s healthcare system, these two critical aspects of care – the clinical journey and the financial one –  often operate in silos. Providers may, in good faith, recommend the best course of treatment. But without transparency around expected costs, patients are left feeling overwhelmed and unsure.

This disconnect has a significant impact. KFF polling indicates that financial anxiety can lead to poor adherence to care plans. When patients don’t understand the financial implications, they may delay or skip treatments altogether, putting their health at risk and ultimately driving up overall costs. As many as 25% of respondents reported skipping or postponing health care in the last year, all because of the cost.

The Disconnect Between Clinical and Financial Conversations

The cost of care can also have an outsized impact on different groups of people. Per KFF, women are more likely than men to say they have skipped or delayed health care because of the cost (28% vs. 21%). Adults ages 65 and older are much less likely than younger age groups to report this tendency. So, how can we bridge this gap?

Here’s where health insurance companies are poised to step up and truly become consumer-centric. By empowering patients with clear and accessible information, they can help them:

• Make sense of health insurance: Many patients struggle to understand the nuances of their plans, from coverage details to out-of-pocket costs.
• Estimate treatment costs: Knowing the potential costs associated with various treatment options allows patients to make informed decisions in consultation with their care team.
• Navigate the care network: Health plans can guide patients towards in-network providers and facilities, maximizing their coverage benefits.

This seems simple enough but it’s actually fraught with complications. For one, healthcare is rich with data. However, this data often lives within disparate systems, making it difficult to provide patients with a central view of their coverage and potential costs. Call center staff have limited visibility and this roadblock might be reflected in their approach to interactions.

Apps can be helpful to patients, but they often fall short when it comes to accounting for individual situations and circumstances. This often leads to frustrated patients calling customer service centers with specific questions that static apps leave unanswered. In some cases, the lack of clarity may even lead patients to make poor healthcare decisions simply because they don’t have a big-picture view of their options. Without clarity around expected financial obligation, they perceive opting out of the system as less of a gamble than facing a daunting bill.

How AI Can Help

Here’s where AI steps in as the solution. Conversational AI, specifically designed to be responsive and contextual, can bridge this information gap by:

• Understanding questions: Unlike static apps, AI can handle complex inquiries and tailor responses to specific contexts. It can understand what a patient is asking and access data from multiple sources, such as a provider directory, fee schedules, and insurance plan details. This allows the chatbot to provide patients with the information they need in real-time, including:
  • Which urgent care center to go to based on location and network status
  • The estimated cost of a specific service
  • How much the patient will likely pay out of pocket based on plan details
• Drawing on a wealth of data: AI can access and analyze data from multiple sources, including health plan details, treatment costs, and in-network providers.
• Providing accurate information: Bad information can be costly on several fronts. Trained on vast datasets, AI ensures information is reliable and up-to-date. Software powered by AI can learn as it goes, calling out patterns and solving problems like a human brain would.

Advanced technology like AI chatbots represents a new era in consumer-centered healthcare. Whether they realize it or not, health insurance companies have great potential and agency in influencing health outcomes.

Making such an investment can mean healthier communities and a more transparent system for all parties. Everyone wins when the clinical and financial journeys are aligned. For instance, payers can expect results like:

• Reduced call center volume: Members can use chatbots to find answers quicker and more directly than they might over the phone.
• Improved member experience: Plan members can provide a faster and more convenient way for members to get the information they need, improving their satisfaction with the health plan.
• Reduced Costs: By helping members navigate their medical decisions with a full picture of the financial impact, payers can more effectively steer members towards lower cost settings.

Looking forward, integrating AI chatbots may be just the beginning of putting the patient experience back at the forefront of healthcare. While the initial focus was on information retrieval, future iterations of the chatbot might take actions on the member’s behalf, such as booking appointments or refilling prescriptions. This makes all aspects of the patient experience seamless, a welcome change from the status quo.

This scenario demonstrates the potential of AI chatbots to revolutionize the health insurance industry. By providing personalized support and streamlining member experience, AI chatbots can not only improve customer satisfaction but also free up valuable resources for insurers. As the technology becomes more advanced, expect to see AI chatbots connecting patients, providers, and payers across the healthcare landscape. Consider this observation: You’re always going to need people and processes. Some will be automated and others manual. Either way, they’ll need to align with technology. That’s a truth you cannot afford to ignore.

If you aren’t looking at modernizing your customer service, you’re missing an opportunity to cut costs while improving revenue cycle management. Wait too long, and you’ll end up behind the curve when everyone else starts implementing AI to provide that concierge service to providers and members.

AI Experts in Your Corner

Thankfully, you don’t have to wait to get started. 3Pillar has extensive experience with building AI solutions for health plans—and we’re leading the charge on offering a more efficient, seamless, and practical approach to revenue cycle management.

To see what this approach entails, download our RCM playbook here.