Portals and IVRs usually provide a status without explaining the logic behind it. Payer workflows often carry multiple versions of the truth at once. A member sees a pending notification. A provider sees a request for medical necessity. A representative sees a coding error or a missing document. Each party is looking at a different fragment of the same event.
Calls rise as those fragments pull apart. A simple prior authorization check turns into a clinical documentation discussion because the self-service view cannot connect the dots. By the time the interaction reaches a person, the representative often lacks the full story or the specific reason for the delay. The member repeats details. Provider offices call back because they are stuck between the plan and the patient with no clear next step.
Volume grows in the gaps between systems, channels, and teams. The question is not whether your contact center can handle the volume. The question is whether the volume is necessary in the first place.
Why self-service creates more work
Self-service was supposed to reduce call volume. Members check their portal for claim status or authorization updates. Providers log in to verify eligibility or submit documentation. The idea was that simple questions would get resolved without reaching a live agent.
The reality is different. Self-service often provides a status without context. A member sees "pending" but does not know what is pending or who is waiting on what. A provider sees "additional information required" but cannot tell if that means clinical documentation, a corrected claim form, or something else entirely.
That lack of context drives calls. The member calls to ask what "pending" means. The representative looks up the claim and sees a different view of the same status. Maybe it is waiting on medical records from the provider. Maybe it is waiting on a coding review. Maybe it is waiting on something the member needs to provide. The representative explains what they see, but their view might not match what the portal shows because the systems update at different times.
Provider offices face the same problem. They check the portal and see one status. They call to confirm and hear something different. They are stuck between the plan and the patient, trying to give accurate information when the sources do not align. That forces them to call repeatedly for the same case because they cannot trust what the portal shows.
The outcome is that self-service generates volume instead of containing it. Members and providers use the portal, get incomplete information, then call to fill in the gaps. The representative spends time reconciling what the member saw in the portal with what the internal system shows. That reconciliation work happens on every call when systems do not share a consistent view.
How multiple systems create multiple truths
Eligibility, benefits, claims, and prior authorizations sit in separate workflows and tools. Each system has its own update cycle, its own business rules, and its own way of representing status. Representatives and BPO partners pull information from multiple systems while the member is waiting on the line.
A prior authorization request might show as "received" in one system, "under review" in another, and "pending medical necessity documentation" in a third. All three statuses are technically correct, but they represent different moments in the same process. The member sees one status in the portal. The provider sees another when they call. The representative sees a third when they pull up the case.
That fragmentation creates confusion and callbacks. The member calls because the portal shows "pending" for two weeks with no explanation. The representative explains that the plan is waiting on medical records from the provider. The provider calls because they submitted records a week ago and want to know why the status has not updated. The representative checks and finds that the records were received but are in a review queue. Nobody is wrong, but nobody has the complete picture.
Handoffs between systems create similar problems. A claim gets denied for a coding error. The denial letter goes out to the member. The member calls to ask why. The representative sees the coding issue and explains it. The member asks their provider to resubmit with the correct code. The provider resubmits but the system treats it as a new claim instead of a corrected claim, which triggers a different review process and a different timeline. The member calls again because they expected a quick resolution and instead see a new "pending" status. The cycle repeats.
What happens when the next representative starts from zero
Notes depend on who handled the interaction and how they summarized it. When the member calls back, the next representative starts with a different context. They read the previous notes, but those notes might not capture the full conversation or the specific language that was used. They ask the same questions to verify information. They explain the status in their own words, which might differ from how the last representative explained it.
That variability creates problems for members who are already frustrated. They called once, explained their situation, and received an answer. Now they are calling again because something changed or because the answer did not resolve the issue. They have to repeat their story. They hear a different explanation. They wonder whether the first representative gave them wrong information or whether the rules changed.
Provider offices experience this even more acutely. They call about a prior authorization and are told that medical necessity documentation is needed. They submit the documentation and call to confirm receipt. The representative they reach has no record of the previous call and asks them to describe what they submitted and why. The provider repeats information they already gave, then waits on hold while the representative searches for the documentation in the system.
The problem is not that representatives are careless with documentation. The problem is that documentation standards vary across teams and BPO partners. One representative might note exactly what was explained and what the member said they would do next. Another might note only the outcome. A third might note the issue but not the resolution. When the next representative reads those notes, they are working from incomplete information.
Why provider callbacks multiply the problem
Provider offices call for updates and confirmations, often covering the same ground because statuses change across systems or get interpreted differently. They are trying to help their patients navigate the plan's requirements, but they cannot do that effectively when they do not have reliable information.
A provider submits a prior authorization request and receives an automated confirmation that it was received. Two days later, they call to check status and are told it is under review. A week later, they call again and are told that additional clinical documentation is required. They ask why that was not flagged earlier and are told that the clinical reviewer identified the need after starting the review. The provider submits the additional documentation and calls to confirm receipt. The representative says it was received but needs to be routed to the clinical reviewer, which will take another few days. The provider calls again a week later and is told the documentation is still in the queue.
Each of these calls is a member of the provider's staff spending time on the phone instead of seeing patients. Each call also takes time from the plan's contact center staff. The work piles up on both sides because the process lacks transparency and the information is fragmented across systems.
Provider callbacks also create problems for members. When the provider office does not have clear information about what the plan requires or when a decision will be made, they cannot give the member a straight answer. The member calls the plan directly. Now both the provider and the member are calling about the same case, asking the same questions, creating parallel workstreams that should not exist.
How gaps compound when volume increases
As call volumes rise, the same issues come back as reschedules and repeat calls. A member calls about a claim. The representative explains the status but cannot provide a timeline because the system does not show where the claim is in the review process. The member calls back a week later to check again. The representative sees that the claim moved to a different queue but still cannot provide a timeline. The member calls back another week later. Each call takes time. Each call adds cost. Each call frustrates the member a little more.
Provider offices face the same cycle. They call to check on a prior authorization. They are told it is under review. They call back several times because the member is waiting for treatment and needs to know whether it will be covered. Each callback takes time from staff on both sides. Eventually, the authorization gets approved or denied, but by that point, multiple calls have happened, multiple representatives have been involved, and the provider has lost confidence in the plan's ability to communicate clearly.
The outcome shows up quickly. Schedules get messy. Follow-up slips through gaps. Members and providers spend their time tracking processes instead of focusing on care. Contact center staff spend their time answering the same questions repeatedly because the underlying information gaps never get closed.
What changes when systems share context
Automation helps when it moves information across the gaps. The member, the provider, and the representative see the same status based on the same underlying data. When the status changes, it changes everywhere at once. When additional information is required, all parties see what is needed and who is responsible for providing it.
AI voice agents can handle routine inquiries about claim status, eligibility, and benefits using real-time data from core systems. They provide consistent answers because they pull from the same source every time. When a status is "pending medical necessity documentation," the AI explains what that means, who needs to provide it, and what happens next. The member and the provider get the same information without needing to call multiple times or speak to multiple representatives.
Real-time guidance for live agents works the same way. When a representative handles a complex call about a prior authorization, the system surfaces the current status, the history of the case, and the specific documentation that was requested and received. The representative does not need to search across multiple systems or interpret conflicting information. They have the complete picture and can explain it clearly to the member or provider.
Accolade reduced after-call work by more than 50 percent by improving documentation and QA. Representatives spent less time rebuilding notes because the system captured what was said and what was committed. When a member called back, the next representative saw accurate notes that reflected the previous conversation. That eliminated the need to start from zero and reduced the time spent reconciling conflicting information.
Why visibility across all interactions matters
Supervisors can review only a small portion of interactions with manual QA. That limited visibility means gaps and inefficiencies spread before anyone notices. When members are calling three times for the same issue, it might take weeks or months for leadership to see the pattern and identify the root cause.
Full-coverage conversation intelligence changes that. Every interaction is captured and analyzed. When repeat contacts spike around a specific issue, leaders see it immediately. When certain claim types consistently generate confusion and callbacks, the pattern becomes visible. When provider offices are calling repeatedly because the portal status does not match what representatives see, that gap gets flagged before it creates thousands of unnecessary calls.
Personify Health expanded QA coverage from about 2 percent of calls to full coverage across all interactions. Leaders got visibility into patterns they could not see with sampling. They identified process gaps, training needs, and system issues that were driving repeat contacts. Coaching became more effective because it was based on actual data about what was causing problems, not on assumptions or anecdotal evidence.
Verida coordinates Medicaid and Medicare transportation and handles around 3 to 4 million calls annually. They added real-time agent assistance and automatic redaction to protect sensitive data. Leaders gained clearer visibility into calls while keeping patient information secure. That visibility helped them identify where information gaps were causing repeat contacts and where process changes could reduce unnecessary volume.
Building operations that close the gaps
Lower cost to serve comes from eliminating unnecessary calls, not just handling calls faster. When members and providers get complete, accurate information the first time, they do not need to call back. When systems share a consistent view of status and next steps, representatives do not spend time reconciling conflicting data.
Start by identifying where the gaps are. Track repeat contacts by issue type. Look at calls where the member or provider is asking for information they should have received from a previous interaction or from self-service. Analyze what is driving those gaps. Is it incomplete information in the portal? Is it documentation that does not match what was said on the phone? Is it status updates that happen in one system but not in others?
Then address those gaps with technology that connects the pieces. Deploy AI agents that pull real-time data from core systems and provide complete answers, not just status codes. Give representatives tools that surface the full history and context so they do not start from zero on every call. Use conversation intelligence to spot patterns in repeat contacts and fix the underlying causes.
The outcome is an operation where volume reflects actual member and provider needs, not information gaps and system fragmentation. Members get answers they can trust. Providers get the information they need to help their patients. Representatives spend their time resolving real issues, not reconciling conflicting data.
Health plans are using AI agents, real-time guidance, and conversation intelligence to close information gaps and reduce unnecessary volume. If you want to see how leading payer organizations are fixing the fragmentation problem, download our ebook: Modernizing Health Plan Operations.
