Meet Amelia, Your Digital Insurance Benefits Agent
The United States leads the world in having the largest per-capita healthcare expenditure exceeding $9,000 per person. While costs are more pronounced in the US, it’s clear other countries and regions have similar burdens. Nevertheless, despite having the largest per-person expense, US life expectancy is the lowest among other advanced economies such as Australia and Canada. Meanwhile, the cost of US healthcare in exceeds $3 trillion and approximately 30% ($1 trillion) is allocated to overall administrative costs including medical billing and related areas.
Nice to see you!
My doctor is recommending an MRI scan. Do I need a referral?
You do, and I can help you submit the necessary information for preauthorization.
Amelia doesn’t blindly follow a set of preset decision trees; rather she discerns customer intent and then works dynamically to lead them toward a resolution.
Surprisingly, a recent survey conducted by the American Medical Association (AMA) reported on average approximately 37 preauthorization insurance requests per week per physician, involving a combination of most staff members including the doctor. These efforts on average equated to approximately 16 hours per week. Recognizing that approximately 850,000 physicians are practicing within the US, these efforts translate into a sizable cost in the billions, and a factor contributing to physician burnout.
Health insurance companies use the prior authorization or pre-approval process to verify that a certain drug, procedure, or service is medically necessary before it is done (or before a prescription is filled). If the service is provided prior to preauthorization, the patient could be responsible for the full cost, with the insurer paying nothing, and the provider faced with further revenue risk.
[Amelia’s] emphasis on ‘conversations and empathic responses’ differentiates the software from more transactionally focused cognitive software.
Preauthorization is a burden to healthcare stakeholders in multiple ways:
It creates financial risk for both patients (if they end up with a large unexpected co-pay) and providers (if they fail to recover the revenue or if there are recovery delays);
It creates administrative costs on both the provider side (as they need to verify coverage/obtain pre-authorization) and the insurer side (as they need to manage the authorization process, often involving multiple iterations as information is missing or incorrect); and
It impacts patient experience, as waiting for authorization delays their care.
Amelia, as an advanced cognitive and conversational AI platform, has capabilities that can deliver beneficial outcomes for all of these stakeholders, reducing costs, increasing revenue capture and improving overall patient experiences.
What Amelia Can Do
Unlike other companies attempting to deliver value to the preauthorization process by clinical support systems, automation systems, or analytics-based entities, Amelia utilizes her broad range of conversational and autonomic system management skillsets. She can simultaneously improve costs and revenue, as well as provider and patient satisfaction.
Current preauthorization-related activities are acknowledged to be fragmented, stressful, costly, and often require multiple successive calls from staff members, including the clarification of and transfer of relevant patient information residing within multiple sources. In addition, the preauthorization process requires the delivery of relevant clinical and administrative information to payer utilization management staff.
We want to provide customers with all the information they need, but not make them feel like they’re talking to software.
I can read human emotion and react with empathy to customer needs or concerns. That’s kind of my specialty.
In addition, Amelia’s natural language, multi-turn and empathetic conversational capabilities allow her to engage in multilateral conversations to clarify information, request missing elements, and keep stakeholders updated on the overall process.
From 10 to 3MINUTES OF AVERAGE CALL TIMEMAJOR GAMING COMPANY CALL CENTER
Amelia’s capabilities and operating environment bring scalable value to the preauthorization process. She can engage with a wide range of stakeholders and integrate with many disparate systems. She can accomplish this by leveraging her unique abilities including but not limited to:
Manage and streamline not only custom workflows but complex integrations with enterprise systems;
Engage with natural unscripted conversation with all staff members and where appropriate third parties, and enable users to switch between multiple requests and topics within a single conversation; and
Generate business intelligence through her advanced analytics capabilities, including machine learning in order to provide valuable patient insights.
Let Amelia Assist With Pre- and Post- Surgery Planning
Let Amelia Assist With Pre- and Post- Surgery Planning
The surgical domain has witnessed the evolution of pre-surgery checklists for several decades. Many studies in reputable clinical publications and news organizations such as The New England Journal of Medicine and The New York Times have documented the importance of adequate pre-operative planning as a major factor in reducing intra- and post-operative complications.
In fact, the World Health Organization (WHO) has undertaken several global and regional initiatives to address surgical safety in general, including a formal surgical safety checklist that is available online. Their checklist includes three categories: before induction of anesthesia, before skin incision, and before the patient is transferred from the operating room. The WHO also has published a care recommendation document that addresses activities within the immediate postoperative period, in order to prevent and prepare for potential issues arising within the home following discharge3, which could lead to readmissions.
Nice to see you!
Can I drink water the morning before my procedure?
No food or water for 24 hours before surgery, and remember you need to arrive two hours before your scheduled procedure.
Cost-benefit analyses of the surgery safety checklist in general have reported findings that point to increased patient safety with a significant decrease in costs related to reduplication of tests, last-minute activities delaying surgical start times, and costs related to medical liability4. This of course also results in much better patient experiences.
Amelia’s advanced natural language functionality and industry-leading emotional intelligence supports strong customer relationships.
Highly-reputable healthcare delivery organizations, such as the Mayo Clinic, likewise have adopted the use of surgical checklists to provide directions for patients several days prior to surgery, activities on the day of surgery, and even what items should accompany the patient to their surgical site.
Although the global surgical marketplace has recognized and adopted the importance of the preoperative and immediate postoperative period checklists, the complex care management within days or weeks of the postoperative environment has not been fully integrated and managed holistically.
IPsoft’s Amelia even recognizes human emotion. The language used can be colloquial, conversational and does not need adapting to fit.
For example, a senior patient with an orthopedic injury such as a torn meniscus will require considerable preoperative workups and follow-up instructions prior to surgery. In addition, this patient will require vigilant care within the immediate postoperative phase including nursing support and physical therapy (PT). Further complexity is added due to the increase of clinical activities within this period at home, such as home-based PT, conducted virtually or in person.
Recognizing the intense pressures on healthcare systems to decrease costs, improve patient satisfaction, and improve clinical outcomes, the entire ecosystem of the surgical preoperative, intraoperative, and postoperative care would benefit from the use of conversational Artificial Intelligence (AI) platforms, such as IPsoft’s Amelia. She can integrate, enhance, and streamline these processes to ensure the delivery of a consistent end-to-end experience at scale.
What Amelia Can Do
Within various surgical-related checklists related to the preoperative and postoperative periods, content ranges broadly from inquiries concerning medications, risk factors such as allergies, whether to shower or not on the day of surgery, and many others.
Amelia’s unique skills sets lend themselves readily to delivering value to patients within the entire span of their surgical experience. Her conversational intelligence enables a patient with a wide range of educational and linguistic backgrounds to communicate using their natural language patterns. Patients can answer and ask questions with ease. With sentiment analysis, Amelia can also detect moods such as sadness or anxiety, as well as satisfaction with the conversation, by analyzing conversation content and pattern.
We need to answer patient questions about their procedures no matter the time of day.
The middle of the afternoon on a Tuesday or 3 AM on Christmas Day, I’m always available to answer patients’ questions. I’ve got this.
Amelia also can interact with a patient by way of a predetermined workflow that has been established by a particular healthcare delivery organization. For example, a healthcare system may require initial questions concerning allergies and other risk-related topics.
88.06%CUSTOMER SERVICE SATISFACTIONMAJOR GAMING COMPANY CALL CENTER
In addition, Amelia possesses an experience management capability where prior patient calls related to their surgery can be referenced, enabling a higher degree of contextualized conversation. For example, Amelia can recall that a particular topic such as shellfish allergy was discussed in a prior call, and this could be then re-verified with a patient.
Pressure is mounting for decreasing patient readmissions to the hospital within the first 30 days of discharge, which is addressable with effective management of the postoperative period. Designing Amelia into the care team and the patient experience, as a digital conversational agent, would have a positive impact, delivering scalable, consistent and sustainable support to patients and their care teams, improving overall experiences and the care outcomes.
The Harvard Business Review recently reported 60% of survey participants considered benefits and related perks to be a major factor in considering a job offer. The survey also stratified benefits that were deemed most valuable by prospective employees; health, dental, and vision insurance were considered to be “heavily weighted” by 47% of men and 61% of women. In addition to these health-related benefits, flexible hours, more vacation time, and work from home options were also very high on the list.
Nice to see you!
I finally joined a gym.
That’s great to hear. Did you know you’re eligible for a gym membership reimbursement with your employee benefits?
According to the US Department of Labor Bureau of Labor Statistics, companies spend on average 25% to 40% of an employee’s salary on benefits. Despite the sizable expense associated with providing and supporting employee benefits, a study performed by the International Foundation of Employee Benefit Plans highlighted ineffective communication as a major flaw within employee benefits management:
Because Amelia is able to handle basic tasks, human staffers are able to focus on more complex and unique ones, which ultimately increases employee productivity.
Only 19% of employees have a “high level” of understanding of their benefits;
80% of employees do not fully read the benefits collateral; and
50% of employees do not understand the employee benefit materials.
Communication is critical as healthcare costs continue to rise, employers change insurance carriers, benefits change, and consumer-driven health plans are implemented. In fact, 65% of employers say employee education is a high priority and 40% of employers now have a budget focused solely on communicating employee benefits.
A recent publication from MetLife, one of the largest global providers of insurance, annuities, and employee benefit programs, indicated that communication is only part of the issue – another is ensuring employees are able to seamlessly navigate their choices and options, enroll into relevant benefits, and file claims when necessary. This aspect of the experience is both costly to administer and often a frustrating experience.
There is simply too much at risk for employees not to fully understand or be able to seamlessly navigate and access their benefits. This is why Artificial Intelligence (AI) capabilities, such as those in IPsoft’s Amelia conversational agent platform, can play an important role in improving employee communication and engagement on benefits, while also making the delivery of this information more efficient.
What Amelia Can Do
There is consensus within the marketplace that poor communication and navigation are an inherent problem for employee benefits management. This lack of communication translates into poor understanding about available benefits among employees, and a lack of knowledge or support on how to access them when needed.
Amelia’s design makes her an ideal fit to deliver value to the employee benefit landscape. In addition to her ability to converse with employees using natural language and understanding, she can assimilate complex text files documenting the business rules related to an employee’s benefits, as well as interoperate with benefit systems.
Our employees need 24/7/365 access to their benefits.
I am always available to give employees the information they need. I’ve got your back (and your employees’ backs as well).
With specific benefits, Amelia could help employees navigate multiple benefit categories including corporate vision plans, physical therapy regimens, and sponsored wellness initiatives such as exercise and weight loss programs. She could also provide information on deductibles for specific procedures such as orthopedic, dental and others. For example, an employee may have a dental benefit plan in place, but may be unsure of relevant details in the event of a dental injury or disease, or how to file a claim. With her integration to back-end systems and information sources, Amelia can provide employee information quickly and accurately, at any time.
4,000EMPLOYEE IT REQUESTS HANDLED IN FIRST THREE WEEKSSEB
Employees and their respective employers will benefit from digital cognitive agents like Amelia that excel within a multimodal communication environment, involving voice and text and other channels. Amelia possesses this capability within her stand-alone version or through integration within a call center.
IPsoft has received positive feedback from existing customers that utilize Amelia in similar scenarios for call and support centers, with Amelia handing more than half of inquiry volume, allowing human colleagues to handle higher-level tasks, complex customers, or both.