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Automating Claims and Payment Status Inquiries in Healthcare
Business Problem
A leading healthcare provider faced mounting inefficiencies in handling claims and payment status inquiries with insurance carriers. Internal staff spent excessive time on hold—up to 30 minutes per call—leading to burnout, incomplete follow-ups, and delayed workflows. These manual processes significantly impacted operational throughput, staff morale, and the organization’s ability to scale and take on larger client accounts. Additionally, reliance on voice calls for status updates hindered real-time visibility and created friction in the revenue cycle.
The organization required a voice and process automation solution to eliminate wait times, enhance operational efficiency, and improve decision-making with minimal dependency on human resources.
Business Solution
Pronix Inc. implemented a voice-enabled AI automation framework to transform the claims interaction process. The solution eliminated the need for staff to manually call carriers by automating inbound and outbound claim/payment status interactions via intelligent voice systems. It also enabled omnichannel access for real-time status updates across web and mobile touchpoints.
The intelligent automation platform provided seamless handoffs for complex cases, ensuring smooth escalation without data loss. Through contextual workflows and natural language interactions, the client achieved faster turnaround, reduced manual workload, and greater scalability.
Technical Solution
The AI-powered Claims Automation Suite was built using a secure, scalable, and intelligent voice and digital platform:
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Voice Bots – Automated status checks with insurance carriers via phone calls, reducing wait time and manual intervention.
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Intelligent Virtual Assistants – Understood and responded to inquiries in natural language across voice and chat channels.
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Agent Handoff Framework – Routed complex queries to human agents with complete interaction history for contextual support.
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Omnichannel Integration – Delivered updates to staff and patients via web portals, mobile apps, and email/SMS.
- Backend System Integration – Connected with the client’s claims management and EHR systems for real-time data retrieval and validation.
Technologies Used
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Customer Success Outcomes
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Reduced Hold Times by 75%: Scheduling appointment was more optimized and scalable. Staff no longer needed to stay on long carrier calls—voice bots handled inquiries autonomously.
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40% Increase in Claims Processed: Automated processes enabled the team to handle larger volumes without hiring additional staff.
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Improved Employee Morale: Reducing repetitive tasks led to a 50% decrease in staff-reported burnout.
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58% Boost in Capacity: Enabled onboarding of two enterprise clients without expanding the team.
- 89% Uptime for Claims Support: With AI managing inquiries around the clock, clients received dependable support and quicker responses without overloading human agents.
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