How a leading health insurance company reduced costly pre-service calls and improved the provider experience with conversational AI

Expertise on call

How a leading health insurance company reduced costly pre-service calls and improved the provider experience with conversational AI

Expertise on call

Client:  Humana
Industry:  Health insurance
Products: Watson AssistantWatson Assistant for Voice Interaction

Overview

One of the largest insurance providers in the United States, Humana offers Medicare supplements, health insurance, dental insurance, vision insurance and pharmacy coverage to more than 13 million customers across the country.

In order to differentiate themselves in what is both a complex and crucially important space, healthcare and insurance companies need to continuously innovate to improve customer service and retention. Consumers expect to receive quick and accurate answers to their queries wherever and whenever they want. Increasingly, providers are forced to rethink their service offerings in order to keep up with user expectations.

Sara Hines

Director of Provider Experience and Connectivity, Humana

“This is just the beginning of how Humana is enhancing our provider communication, and I’m excited to keep exploring the infinite possibilities of artificial intelligence.”

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Challenges with legacy systems

Humana’s interactive voice response (IVR) system was transferring far too many calls to human agents, at tremendous cost to the company and its customer satisfaction scores. Administrative staff from healthcare providers contact Humana via phone with inquiries about Humana members' health plan benefits and eligibility. Humana receives over 1 million provider calls every month, and most callers were opting out of the IVR system to be directed to outsourced call centers, for which Humana paid by the call. More than 60% of these calls were related to routine, specific, pre-service questions with well-defined answers.

To meet ever-growing user expectations, Humana needed a way to completely rethink how they addressed customer queries. The Humana Provider Services Innovation (PSI) team was charged with finding a solution that could better address these costly pre-service calls and improve the provider experience.

Getting healthcare professionals the information they need, when they need it

Conversational assistants were not as ubiquitous or advanced as they are now when Humana began this journey in 2016, but the company recognized the profound promise of AI in customer care. Humana chose to work with Watson, the industry leader in enterprise AI, and began a collaboration with IBM's Data and AI Expert Labs & Learning (DAELL). After a three-month proof of concept, Humana and IBM began development of what became the Provider Services Conversational Voice Agent with Watson. The solution combines multiple Watson applications in a single conversational assistant, run on the IBM cloud, while the Watson Assistant for Voice Interaction runs on premise at Humana.

Humana's Voice Agent with Watson provides a faster, friendlier and more consistent way for administrative staff at healthcare providers to access pre-service, medical eligibility, verification, authorization and referral information without the need to speak with a live agent. The solution relies on AI to understand the intent of a provider's call, verify they are permitted to access the system and member information, and then determine how best to provide the information requested.

“This is not the type of technology that you set up and walk away. It needs monitoring, training and supervising to harness the true insights that can be brought forth.”

The Voice Assistant uses significant speech customization with seven language models and two acoustic models, each targeted to a specific type of user input collected by Humana. Through speech customization training, the solution achieves an average of 90-95% sentence error rate accuracy level on the significant data inputs. The implementation handles several sub-intents within the major groupings of eligibility, benefits, claims, authorization and referrals, enabling Humana to quickly answer questions that were never answerable before. In the previous IVR system, a request for “benefits” could lead to a seven-page fax. Now, the Watson solution is able to respond with a specific “point” benefit, such as, “the co-pay for chiropractic visits is $100”.

What's next for Watson and Humana

The solution started handling live calls from healthcare providers in April of 2019, with several updates throughout the year to expand functionality and the user base. It has been able to handle inquiries at about a third the cost of the existing system, and it has also had a higher overall response rate – almost double that of the previous automated IVR system.

Over the course of development, the IBM Watson Expert Services Lab team drove improvements in Watson services with custom training and models better able to understand healthcare terminology in a low-bandwidth call center environment. This has led to several pending patent submissions, and the team has published tools, guides and methods for building, testing and tuning a large Watson Voice Assistant solution. Humana's Voice Assistant solution pattern recently became formalized in the Watson Assistant for Voice Interaction solution offering.

“We did it blindly: We did not tell providers that they were going to be in the new environment, because I wanted to understand their reactions, so we could tweak and continue to evolve Watson and watch.”

“Humana's Voice Agent has greatly improved self-service capabilities for Humana healthcare providers, allowing them to quickly and efficiently get information on patient insurance coverage across a variety of data points. Providers can now call into the Watson-based solution and complete an inquiry in about two minutes without waiting to reach a call center representative. "We've got a level of insight that we've never had before in these interactions,” said Sara Hines, Director of Provider Experience and Connectivity at Humana.”

The solution receives more than 7,000 voice calls from 120 providers per business day, and feedback from users has been incredibly positive. “Humana’s initiative with Watson was three years in development and continues to grow even after implementation,” said Hines. “This is just the beginning of how Humana is enhancing our provider communication, and I’m excited to keep exploring the infinite possibilities of artificial intelligence.”

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