High call volume usually starts long before the phone rings. For most payers, the real issue is payer member engagement: unclear communication, broken digital journeys, and member confusion. That shift matters because it changes where payers should focus first.
High inbound call volumes are often the result of fragmented member communication, unclear content, and self-service tools that weren’t designed for the people who need to use them. The organizations reducing contact center pressure aren’t doing it by adding more agents or deploying more deflection automation. They’re fixing the moments that trigger the call to begin with.
This piece outlines how health plans can reduce avoidable contacts, improve member and provider engagement, and shift from answering admin questions to building stronger member relationships, while improving plan ratings and lowering service costs.
Every year, health plans invest in new contact center capacity, better IVR routing, and more deflection automation, and call volumes stay stubbornly high. The reason is straightforward: those interventions do not treat the root cause, and they only address the symptoms on the surface.
Members generally aren’t calling because they prefer the phone. It’s often because they couldn’t find a clear answer, couldn’t complete a task digitally, or received a communication they couldn’t understand. A member call is often the last step in a journey that has already gone wrong.
Payers that improve engagement upstream through clearer communication, better digital design, and proactive outreach reduce call volume in a lasting way rather than simply addressing short-term spikes. That’s how payers stop chasing volume and start preventing it.
Not Every Call Is the Same, and Most Avoidable Calls Share a Common Root
Many health plans already sort calls by complexity, and that helps with routing and staffing. But it misses the more important question: which categories of calls should never happen at all?
There are three broad interaction types:
- Transactional inquiries: questions about insurance, eligibility, benefits, cost estimates, and plan details. These represent the largest share of inbound volume and are the most avoidable. When digital tools work well and communications are clear, most of these contacts will disappear.
- Multi-issue interactions: members calling with layered or complex questions, often because an earlier simpler touchpoint left them with unresolved uncertainty. Human-plus-AI support, where advisors are equipped with real-time context and clear guidance on what to do next, makes these interactions faster and more satisfying.
- High-complexity and high-value contacts: members managing serious conditions, high-cost situations, or long-standing plan relationships. These deserve a concierge-level experience with an empathetic human in the loop, equipped with full member context to deliver meaningful, personalized support.
Most plans invest disproportionately in handling transactional calls rather than eliminating them. Shifting that investment upstream to communication clarity, content design, and digital experience, is where measurable contact reduction begins.
The Root Cause: A Communication Problem, Not a Call Problem
The biggest opportunities to reduce calls aren’t inside the contact center; they’re in the content, communications, and digital experiences members encounter before they ever consider calling.
Member communication represents one of the largest opportunities for improvement for most health plans. Consider the Explanation of Benefits (EOB): one of the most frequent drivers of member calls is confusion over what they owe and why. When EOBs are redesigned for plain-language clarity, with a clear summary of patient responsibility, plain-English descriptions of service adjustments, and a direct link to a cost estimation tool, call volume from post-claim confusion drops materially. The same principle applies to plan selection documents, prior authorization notices, and annual benefit summaries.
A better approach is to manage content with the same rigor as any core product or service. That means:
- Creating content that is structured, consistent, and AI-ready, so it can power chatbot responses, IVR scripts, and advisor knowledge bases without requiring constant manual maintenance.
- Simplifying standard operating procedures for content management so updates appear consistently across channels.
- Using behavioral data to identify which communications are generating the most follow-on contacts and redesigning those first.
Payers have real latitude here. While regulatory requirements govern what must be communicated, they do not dictate how. The plans that reduce friction most effectively are those that treat regulatory disclosure as a floor, not a ceiling, and design member communications to build understanding rather than satisfy compliance checklists.
Self-Service Only Works When the Experience Is Designed for Confidence
Digital deflection strategies often fail because the self-service experience wasn’t built for them. Significant proportions of members actively want to manage their benefits digitally, reviewing claims, checking plan details, finding care, and estimating costs, but engagement with payer portals and apps remains low at many plans.
When members say they want digital tools but don’t use them, poor design is usually the reason. Most payer digital tools were built around internal processes, then pushed out to members, producing experiences that are logical to administrators and confusing to members. Closing that gap requires redesigning experiences from the member’s perspective, with mobile-first usability, plain-language content, and clear next steps and less confusion.
Cost estimation tools are a compelling example. Since the Transparency in Coverage regulations took effect in 2021, most major payers have deployed them, but adoption remains low because the experience is often too complex or unclear. A well-designed cost estimator, integrated with real-time eligibility and presented in plain language, can prevent calls. A poorly designed one generates new contacts from members who tried it and still couldn’t get an answer.
The Technology Layer: Agentic AI and Intelligent Automation
Behind the best member and provider experiences is a technology layer that works quietly in the background. Agentic AI—systems that can autonomously complete multi-step tasks on behalf of users, not just answer questions—is becoming more important for plans that want consistent service at scale.
In practice, this spans a range of capabilities:
- AI-powered natural language understanding in IVR, so members can describe their needs in their own words and be routed accurately, reducing misrouted calls and transfer rates.
- Conversational AI virtual assistants, both chat and voice, capable of handling simple tasks from start to finish, including confirming eligibility, explaining benefits, and processing simple requests.
- Advisor assist tools that surface real-time context, suggested responses, and recommended next steps during live interactions, reducing handle time and improving first-contact resolution.
- Back-end integration and API orchestration that connects these capabilities to the right systems and data, so every channel delivers a consistent, accurate, and personalized response.
The plans deploying these capabilities most effectively view them as the foundation of a better service strategy, with contact center efficiency emerging as the outcome rather than the primary objective.
From Transactional to Relational: What Health Plans Actually Want
Health plan leaders aren’t chasing lower call volume for the sake of it. They want fewer confusing, administrative calls and more conversations that help members navigate care, manage chronic conditions, and use their benefits with confidence.
That shift means spending less time on admin confusion and more time helping members. It requires clearing the queue of low-value, avoidable contacts so that advisors and care navigators have the capacity and the information to deliver high-value interactions when they matter most.
In a highly competitive plan market, where differentiation on benefits is increasingly difficult to sustain, service quality and experience have become key retention drivers. Plans with consistently high member satisfaction ratings retain members at significantly higher rates, and STAR rating improvements of even half a point carry substantial revenue implications in Medicare Advantage markets.
Loyalty Is a Two-Sided Equation
Member experience and provider experience are not separate problems. Providers contact payers on behalf of members at high volume, for eligibility verification, prior authorization status, claims inquiries, and referral coordination. A significant share of avoidable member contacts is mirrored by avoidable provider contacts on the same issues.
Plans that simplify the administrative experience for both sides simultaneously see stronger results from the same investment. A provider portal that delivers real-time eligibility and authorization status reduces calls from both the provider’s office and the member who was waiting on the outcome. Solving for one side and ignoring the other leaves value on the table.
The same things that improve member experience also matter on the provider side: clearer communication, better tools, and less friction.
How to Improve Provider and Payer Member Engagement
If your plan wants to reduce avoidable calls and improve service quality, start with payer member engagement. Concentrix partners with health plans, payers, and managed care organizations to address the full engagement challenge, from strategy through execution.
Our approach includes:
- Member and provider experience design: journey mapping, communication redesign, digital experience optimization, and self-service strategy grounded in behavioral data and member insight.
- AI-enabled contact center operations: intelligent automation, agentic AI deployment, advisor assist tooling, and conversational AI that reduces avoidable contacts while improving the quality of necessary ones.
- Technology and operational integration: connecting experience design to the system and workflow changes needed to deliver consistent, personalized service across every channel.
- Outcomes-based measurement: linking experience improvements to the metrics that matter most to health plan leaders, including contact reduction, first-contact resolution, STAR ratings, NPS, and cost-to-serve.
We build this capability around what payers actually need: not another point solution for call deflection, but a partner that connects member expectations, the operations behind them, and the technology required to scale.
