Half of insured adults struggle to understand their health coverage (KFF, 2023), while physicians spend 13 hours per week on prior authorization paperwork (AMA, 2024).
Both of these prevalent issues have a negative impact on healthcare payers, in two critical ways: declining member satisfaction and rising administrative costs.
These issues manifest in two main areas:
- Coverage confusion around routine procedures, especially after regulatory changes
- Prior authorization delays, especially after new policy implementations
Healthcare leaders scramble to understand member reactions:
- "Are patients losing confidence in our coverage?"
- "Which policies are causing the most confusion?"
- "How are our agents explaining the new requirements?"
Traditional feedback mechanisms — such as surveys, manual call reviews, and member panels — can take weeks to provide answers. But healthcare decisions can't wait when member confusion leads to delayed care or treatment gaps.
The complexity of the healthcare space compounds these issues.
The healthcare complexity challenge
Policy implementation is multifaceted. The healthcare industry faces constant regulatory changes that often create cascading confusion. These include, but are not limited to, new Centers for Medicare & Medicaid Services (CMS) guidelines, updated prior authorization requirements, coverage modifications, and evolving compliance standards.
Newly powered by data-driven feedback, leaders can make policy changes based on a deep understanding of patient concerns, as they are happening. They can share real-time guidance with agents to ensure they follow the procedure in conversations around the regulation.And there is a speed mismatch.
Healthcare regulatory changes prompt immediate questions from members, even when formal compliance deadlines are months away. However, traditional feedback methods can't keep pace with member reactions — especially in a world where access to information (which is not always accurate) is one click away.
At the end of the day, healthcare providers must balance regulatory compliance, member satisfaction, and cost management simultaneously.
Certainly not a simple task.
How conversation intelligence mitigates these healthcare challenges
Real-time conversation intelligence changes this dynamic entirely by providing immediate insights into member conversations.
Two real-world applications demonstrate how conversation intelligence delivers the clarity healthcare leaders need, at the speed they need it.
1. Keeping a pulse on customer voice during regulatory changes
Healthcare organizations must adapt to regulatory updates that affect different aspects of operations, coverage, and compliance requirements throughout the year.
When these changes occur, leaders want to know, "What are agents and patients saying about the new regulations?"
The data reveal that customers ask some version of "How will recent changes to CMS guidelines on Medicare Advantage coverage affect my upcoming procedure?" Detailed reporting uncovers conversations where the regulation change is discussed.
With conversation intelligence, leaders can drill down even further, if they so choose, and ask more nuanced questions, such as, What's confusing patients? What are they apprehensive about? What are they angry about?
2. Identifying the root cause of the most pressing call drivers
As mentioned above, physicians and their staff spend an average of 13 hours per week completing prior authorization-related tasks.
Customers often contact call centers about prior authorization, but what specifically do they ask about?
With conversation intelligence, leaders can see calls that mention “prior authorization,” in its various forms. From there, they can identify specific patterns — such as billing questions, procedure approvals, and medication coverage — and track which issues are resolved the fastest, how, and by which agents.
Conversation intelligence empowers leaders to immediately investigate what's blocking resolution in these specific cases and helps their team understand member-specific concerns and resolution drivers.
But that's not all.
Conversation intelligence can also help with:
- Coverage clarity: Identify which benefits explanations reduce vs. increase member confusion
- Compliance monitoring: Ensure agent communications meet regulatory requirements in real-time
- Member retention: Understand unenrollment drivers and address root causes proactively
And more.
In an industry where member uncertainty can directly impact health outcomes, conversation intelligence provides the immediate clarity healthcare leaders need to make informed decisions.
From regulatory complexity to clear member communication
With Cresta AI Analyst, leaders can ask natural-language questions about their customer conversations and get instant answers backed by real conversation data.
Whether healthcare leaders need to understand member misunderstanding about policy changes, identify specific prior authorization concerns driving call volume, or determine which communication approaches reduce versus increase member frustration, AI Analyst delivers evidence-based insights in minutes rather than weeks.
Healthcare providers who use Cresta AI Analyst can navigate regulatory complexity with confidence, ensure compliance without compromising member satisfaction, and make data-driven decisions that protect both member trust and health outcomes.
Learn more about AI Analyst's capabilities, then connect with our team for a personalized demo.
