It’s just a phone call. What could be so complicated?

At first consideration, conducting – and even automating – phone calls to major medical payors and pharmacy benefit managers (PBMs) to perform benefit verifications doesn’t seem as if it should be all that complex. After all, these calls are extremely common, extremely frequent, and entirely necessary. And yet, acquiring the necessary data with accuracy is far from a straightforward task.

At their core, these phone calls have a singular objective: to collect the data necessary to get patients access to the right treatments promptly. The swifter patients receive their required treatments, the closer we come to saving lives.

Stick with me here, but understanding the complexities involved can be easier if you think about completing benefit verification calls as a three-act performance.

Setting the scene: The fragmented healthcare landscape

The US healthcare landscape is known for its fragmentation. Much of the vital data we need to complete benefit verifications and get patients on much-needed therapies isn’t available digitally directly from payors or third-party electronic solutions. 

While some third parties do offer digital data, it can often arrive incomplete or even outdated. The remaining data is scattered across a diverse terrain of non-digital formats – PDFs, scanned documents, and even the physical world of post-it notes. It’s a landscape we can’t navigate easily through APIs … at least, not yet.

Act I: The prelude of pre-call workflows

As you’ve likely gleaned from the above, healthcare’s fragmented landscape means there’s a lot of work that needs to happen before an actual benefit verification call commences. For those conducting calls manually, that means time-consuming pre-call research. Infinitus’ work begins with our pre-call workflows. Here, we embark on a mission that involves API integrations and the art of data ingestion. 

Each workflow requires significant work because, in the world of healthcare, not all phone calls to payors follow the same path, and even within a single payor, the number to call may differ for different treatments or the department you need to get in touch with. The lack of standardization among payors – and even when calling the same payor – is a significant challenge, creating complexity for manual callers and Infinitus’ AI solution alike. As an example: even if two patients share the same insurance payor and plan, a caller may need to dial different numbers depending on their unique circumstances. 

In order to automate the calls themselves, Infinitus must first automate all the work that would otherwise require a healthcare worker, an Internet connection, and a substantial amount of time.

Act II: The conundrum of electronic data

In an ideal world, healthcare data would seamlessly flow digitally between payors, providers, pharmacies, pharmaceutical manufacturers, and patients, rendering phone calls obsolete. However, reality doesn’t align with this ideal (at least, not yet). Infinitus uses electronic data sources, in part to collect as much data as possible before a call commences – which in turn helps keep calls as short and efficient as possible, but as referenced above, electronic data isn’t always reliable.

Thus, we’ve honed our analytical capabilities and embraced sophisticated A/B testing involving electronic sources. Our aim is not only to ensure consistency across various electronic solutions but also to periodically validate those data sources by collecting information through the Infinitus digital assistant during calls. These meticulously designed processes ensure the accuracy of the information gathered both before and during our calls.

Act III: The compelling call conversations

Our story arc gains complexity as the actual benefit verification calls to payors unfold. Our digital assistant needs to be capable of speaking like, and speaking to, a human. That means it needs to be able to respond in seconds and understand the myriad ways a question could be asked or information could be provided, so the agent on the other end doesn’t get frustrated or hand up. And even beyond that, during calls, a few “subplots” can emerge beyond the conversation and collection of data: 

  • Navigating IVRs: Before even talking to a live agent, your employee or the Infinitus digital assistant must get through the automated call portion – and these differ from payor to payor, number to number.
  • Escalations: Scenarios can emerge when payor agents steer our journey toward different departments, occasionally involving third-party administrators. 
  • Transfers: These add an element of suspense, placing the digital assistant on hold – sometimes for more than an hour. That’s a period that could otherwise be used productively by healthcare professionals in patient care, though our digital assistant doesn’t mind waiting. 
  • Agent provided information that doesn’t match SOPs: the Infinitus digital assistant metaphorically raises its hand, signaling the necessity for human review of this critical information, sometimes prompting the initiation of a followup call to confirm certain information
  • Agents behaving badly: On some occasions, we might even find it necessary to initiate calls anew.

Finale: The harmony of post-call heuristics

In this healthcare “performance,” while validation tests have their moment during calls, the grand finale unfolds with the post-call heuristics. Even when situations arise on a call where information appears inaccurate, the Infinitus digital assistant metaphorically raises its hand, signaling the necessity for human review of this critical information, sometimes prompting the initiation of a followup call to confirm certain information. 

These processes bring our work to conclusion, ensuring that the information we’ve collected enables healthcare providers, pharma hubs, and patient support programs have the information necessary to get patients on therapy. 

Interested in learning more about how we’re accomplishing this? Speak to Infinitus today.