In an era where digital convenience is all-important, one truth remains: nothing replaces the comfort of speaking with a real human being, especially in healthcare. Whether it’s resolving a billing issue or clarifying coverage eligibility, live interaction often provides the empathy and understanding that automated systems struggle to deliver.
Yet, many companies are facing a tough balancing act. Staff shortages, rising customer expectations, and the relentless demand for operational efficiency are pushing customer service teams to their limits. The deployment of AI, however, is changing the way healthcare organizations maintain a high-quality, human-centered experience without burning out human agents.
AI: The New Contact Center Support Team
AI is changing the contact center experience for human agents and health plan members for the better. In healthcare contact center settings, AI-powered chatbots can engage in conversations with tone, nuance, and even emotional awareness. These systems can detect frustration or impatience and escalate issues to human agents when needed.
The result? A smoother, more responsive experience for members and improved efficiency for human agents.
Some contact centers use AI to analyze live conversations between human agents and customers. These models can detect keywords, emotional signals, and sentiment trends, then offer suggested responses or next steps to the human agent. It provides real-time guidance for them without disrupting the call flow.
Keep the Human Connection
No matter how good AI is today or becomes in the future, it’s important not to lose sight of an essential element: the human connection.
The goal is to have healthcare organizations use AI to empower and support human agents rather than constrain them or take their jobs. Bringing humans and AI together can solve staffing shortages, lack of expertise, and the need to quickly resolve member calls to improve satisfaction and retention.
A study from Stanford Digital Economy Laboratory and the MIT Sloan School of Management offers evidence of this. Researchers followed more than 5,000 customer service agents at a Fortune 500 software company for one year. The results were striking:
- Agents using AI-generated scripts resolved 14% more issues per hour on average
- Novice and lower-skilled agents saw a 34% boost in productivity
- Requests for managerial help decreased
- Employee retention improved
As healthcare payers continue to evaluate the role of AI in member services, the imperative should be to enhance the work done by human agents, not replace them. Forward-thinking payers are already looking toward AI as a way to empower teams, optimize operations, and elevate the member experience while maintaining the human touch that defines compassionate care.
Ensure Compliance, Build Trust
At the same time, ensuring compliance and trust remains essential. As AI becomes more deeply embedded in contact center operations, healthcare organizations must navigate a complex regulatory environment. Solutions must align with HIPAA standards to ensure protected health information remains secure and confidential, particularly in AI applications that analyze or generate content during live interactions. Additionally, the Centers for Medicare & Medicaid Services has issued evolving guidance on the use of automated tools in Medicare and Medicaid communications, reinforcing the need for transparency, oversight, and auditability.
Legislation like the One Big Beautiful Bill Act (OBBBA), aimed at streamlining and clarifying healthcare billing for patients, adds another layer of accountability. AI tools that assist with member billing inquiries must not only be accurate but also explainable to deliver information in a way that supports member understanding and reduces confusion. Building trust means designing AI that’s compliant by design and centered on helping people navigate their care more easily, not adding to the complexity.
When thoughtfully deployed in contact centers, AI can play a key role in easing administrative burdens. By automating repetitive tasks such as eligibility verification, claims triage, and routine inquiries, AI helps reduce operational costs, improve scalability, and free up contact center staff to focus on emotionally complex interactions. The combination of AI and human skills supports consistency across all contact center channels.
The AI End Game
One of the key takeaways from the MIT/Stanford study is that the AI system wasn’t designed to replace human agents; it was built to support them. By capturing best practices and offering real-time suggestions, AI helped people perform better without taking away their autonomy or judgment.
This approach reinforces a key principle: customer service is, at its core, a human endeavor. AI should be used to protect and enhance human emotions and cognitive abilities, like empathy, flexibility, and critical thinking, which make human agents invaluable.
As payers continue to explore the use of AI in member services, the goal shouldn’t be to replace people, it should be to empower them. When used thoughtfully, AI can reduce stress, improve performance, and create better experiences for both customers and human agents.
In the end, the best member service solutions won’t be purely human or purely digital; they’ll be a seamless blend of both, designed to assist, support, and create exceptional member experiences while cutting costs.
Chris Shiffert
Chris Shiffert is a Senior Vice President at BroadPath, a Sagility company.
