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By Abhishek Danturti Sharma

Healthcare payers and providers are increasingly challenged to raise the bar for consumer experience. And tech enablement is essential to realizing the evolving value propositions. On the front lines of experience and engagement, contact centers are set for a profound transformation. Generative AI (GenAI) and agentic learning systems are evolving to operate with greater autonomy and adaptation through continuous feedback. These disrupters are now driving the contact center shift—from traditional, reactive service hubs into proactive, intelligent coordinators that bridge the gap between payers, providers, and patients. GenAI, as key enabler, promises to streamline complex healthcare workflows, enhance collaboration, and deliver more personalized and efficient services.

From Transactional Interactions to Strategic Collaboration

Healthcare contact centers have traditionally played a crucial role in managing interactions between payers, providers, members, and patients. These centers handle tasks ranging from claims processing to care coordination and provider network management. However, the complexity of healthcare processes often makes these tasks cumbersome, leading to delays, administrative burden, and a less-than-ideal experience for all parties involved. GenAI has the potential to transform these centers into strategic assets that go beyond basic support.

With GenAI, healthcare contact centers can deploy intelligent agents capable of executing complex, multi-step workflows autonomously. These AI agents can manage claims processing from start to finish, ensuring that all required documentation is in place, verifying coverage details, and coordinating with providers to resolve any discrepancies. This automation reduces the administrative burden on both payers and providers, allowing them to focus more on patient care and outcomes rather than administrative tasks. For example, the clinical administrative burden can be upwards of 50%. Many of these tasks can be easily automated—with fewer follow-ups downstream in areas of the lifecycle related to payment, medical record abstraction and review.

Enhancing Communication and Coordination Between Payers and Providers

One of the most significant advantages of GenAI in healthcare contact centers is its ability to facilitate seamless communication and coordination between payers and providers. AI agents, equipped with natural language processing, can interact with both parties in a more human-like manner, interpreting complex queries, providing clear explanations, and ensuring that all parties have the information they need to make informed decisions.

For example, a provider might reach out to a contact center to clarify the details of a patient’s insurance coverage for a specific treatment. Instead of navigating through multiple departments or waiting for a callback, an AI agent can instantly access the patient’s coverage details, verify the necessary pre-authorizations, and provide real-time updates to both the provider and the patient. This not only speeds up the process but also reduces the potential for miscommunication and errors, leading to a smoother patient experience.

Streamlining Complex Healthcare Workflows

Healthcare is fraught with intricate processes, particularly when it comes to managing claims, billing, and compliance. GenAI agents are uniquely positioned to handle these complexities by automating workflows that traditionally required significant human effort. For instance, an AI agent could be tasked with managing the entire lifecycle of a claim—from submission and review to approval and payment—ensuring that each step adheres to regulatory requirements and payer policies.

AI-driven workflows can adapt in real time to changes in regulations, provider contracts, or patient needs, making them far more resilient and responsive than traditional rule-based systems. By integrating with existing systems, AI agents can pull data from various sources, analyze it, and take appropriate actions without requiring manual intervention. This level of automation helps reduce delays, minimize errors, and ensure compliance, ultimately improving the efficiency of both payer and provider operations.

Preparing for the AI-Driven Future in Healthcare

As healthcare organizations prepare to and are integrating GenAI into their contact centres, it’s crucial to approach this transition with careful planning and strategic foresight. Payers and providers will need to work together to codify their workflows, ensuring that AI agents are equipped with the necessary knowledge to operate effectively. This collaboration will also be vital in maintaining a balance between automation and human oversight, particularly when it comes to ensuring compliance with industry regulations and ethical standards.

In light of all of these optimized outcomes—we can say that the future of healthcare contact centers is bright, with the advent of GenAI. These centers will not only become more efficient and responsive but will also play a pivotal role in enhancing the overall healthcare experience for patients, payers, and providers alike. As AI continues to evolve, these contact centers will transform from being mere intermediaries to becoming integral partners in the healthcare ecosystem, driving better outcomes and more efficient care delivery across the board.

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Abhishek Danturti Sharma is Associate Vice President, Business Transformation at Sagility where he leads the company’s cognitive and AI initiatives in a consulting and solution delivery capacity. Abhishek is responsible for and executes the digital product and innovation agenda across the healthcare organization. He is an alumnus of the University of Maryland, College Park and BITS-Pilani, India.

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