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Driving Member Experience and Operational Efficiency with Conversational AI

THE CLIENT

 

Our client is a Massachusetts-based non-profit health insurer with 2.8 million policyholders. It is recognised for its innovative services, benefits and plans aimed at reducing healthcare costs and improving quality of care.

THE CHALLENGE / REQUIREMENT

In 2024, the client faced unprecedented volumes of customer support requests (~1.7M Calls, 209K chats) and lacked after-hours self-service. To address this, it sought AI-driven automation, personalization, and decision support to enhance member engagement and experiences, and operational efficiency.


As a first step, the client launched an enterprise chatbot in its member portal, leveraging conversational AI to:


  • Provide 24x7 coverage.
  • Reduce wait times during business hours.
  • Offer members a convenient, multi-channel platform for support.

THE SOLUTION

 

We implemented a chatbot framework powered by Kore.ai’s XO platform to automate common inquiries, while seamlessly escalating complex issues to human agents. The scope of queries covered claims status and reasons for denial (providing total visibility), as well as requests for ID cards (both physical and electronic) for medical, dental and vision services.

The chatbot was deployed on the Kore SaaS Cloud environment, with effective integration to the client’s Claims Application System, Cisco ECE Agent Desktop Application, and Medallia.

Using our domain expertise, we designed a simple and efficient member journey for our client’s members with the following steps:

Through this project, we:

  1. User logs on to member portal.
  2. Interacts with the chatbot to inquire about all self-service use cases.
  3. Chatbot resolves inquiries — or directs user to a human agent in the event that it is unable to identify or resolve a self-service inquiry within the automation.
  4. Live human agents address the query on Cisco ECE Agent desktop application.

The Mphasis and Kore.ai partnership brings best-in-class, conversational and generative AI solutions to our clients, enabling new standards for customer, employee, and agent experiences for your business.

BUSINESS BENEFITS

Increased service center capacity through both automated and live chat.

Reduced call center volumes and operational costs

Improved self-service resolution rates, particularly first contact resolution (FCR).

Higher member satisfaction and loyalty, reflected in Net Promoter Score (NPS) and Customer Effort Score (CES).

For the members, the solution provided convenient and round-the-clock access to essential support services, and faster resolution of common questions.This significantly improved confidence and satisfaction in navigating the client’s healthcare services.