An AI voice agent for payer calls is software that phones a health insurer on behalf of a clinic or billing firm, and asks about a patient's cover or an unpaid claim. In the United States, insurers are called payers. Billing staff used to spend hours on hold for these calls. These agents are sold to American providers, and some are built by companies with engineers in Bengaluru.
Why are phone calls still needed? A clinic can check much of a claim's status electronically, through a healthcare clearinghouse. But the electronic answer is often short, such as "pending". To learn why a claim is pending, or what exactly a plan covers, someone must call the insurer's line for providers and ask a representative.
Take, for example, a billing firm that handles the claims of a heart clinic in Pittsburgh, Pennsylvania. Forty of the clinic's claims to one insurer are still unpaid after 45 days. The firm's revenue cycle management (RCM) system gives the list to the voice agent. The agent dials the insurer and answers its automated phone menu, which is called a conversational IVR. Then it waits on hold, for about 40 minutes on this call. A person never has to listen to the hold music.
When a representative answers, the agent gives the clinic's identification number and the first claim number. It asks for the status and the reason. It goes through the claims one by one. The representative says that 34 claims are approved and will be paid next week. Six claims are waiting for medical records. The agent writes each answer into the claim in the RCM system. It also opens a task for the six claims, so that an employee or an AI billing agent sends the records.
The agent uses speech recognition to turn the representative's words into text. A language model then works out what was said, such as a claim number or a reason, and decides what to say next. A speech model reads the reply aloud. The design is the same as a voice bot that answers a customer care line. The difference is the direction. This agent makes the call, and the person on the other end is a trained insurance employee.
Some insurers now answer such calls with their own voice bots. So, more and more, one company's agent asks the question and another company's agent answers it.