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Healthcare Payers – Here’s How You can Digitally Transform Member Experience

Abzooba Admin

– Presales Team


A growing number of healthcare payers are embracing digitization and transforming the way in which they interact with members. If properly integrated, technology revolutionizes the way members are served, be it in automating back-office functions or via chatbots and other artificial intelligence (AI)-guided systems for providing instantaneous responses to customer questions or for sorting through thousands of data points to find the right premium or mitigate risk.

Members are taking a more active part in healthcare decision making, and they have multiple interactions with payers that strongly affect those decisions—including which health plans to select, what types of providers to consult, what treatments to use (and where to receive them), and how to get the most from their healthcare dollars.

Opportunities & Use Cases

Technology has been transforming every industry in significant ways and digital technology-led transformation has engulfed the healthcare sector also immensely. Digitization brings measurable data and technology that can deliver considerable benefits. Here’s what can be achieved:

    1. Healthy Reward Program

Focusing on behavioral change to improve health and control costs is a central concept of member engagement. The premise is that the motivating power of financial rewards for practicing healthy behavior can make a significant impact on the efficiency and effectiveness of health care. Using incentives to change unhealthy behaviors is related to two trends: value-driven purchasing, which involves providing members with information about health care quality and costs, and member-centered care. Each of these movements encourages people to take a more active role in their care.

    Solution: Care 360: Community-based Healthy Reward Program

Care 360 is an application that rewards members for taking small steps that help them live a healthy life by measuring member behavior with multichannel eco-system to reward members automatically. It leverages data and analytics to customize consumer offerings and partnership pairing and helps payers to engage members beyond traditional outreach by leveraging social determinants of health factors. Members can leverage Care 360 coins at community level, in addition to individual benefits. When connected to smart home devices such as Google Home and Amazon Alexa members can use voice commands to track activities, check health appointments and get medication reminders.

    2. Member Satisfaction

Analytics can help in designing member outreach programs aimed at dissatisfied members to reduce their dissonance and complaints.

    Solution: Complaints Prediction

Using predictive analytics to identify Medicare members at risk of lodging a complaint with CMS about the payer. Focus resources on meaningful outreach programs to reduce such complaints by resolving outstanding issues.

    Solution: Gaps in Care Analytics

Advanced analytics to create a rules engine that can identify possible care gaps in treating conditions before they reach an advanced stage. Results from the rules engine are used to enable timely outreach and communication with members, allowing for subsequent non-emergency treatment.

    3. Customer service will never lose its human touch

Payers that have doubled down on customer service through investments in a multichannel approach and adopting digital tools have been rewarded with greater customer loyalty. However, the companies that are succeeding are the ones using technology to augment their contact center agents’ capabilities, rather than to replace the human touch.

    Solution: Cognitive Search for Contact Centers

Deep Learning and NLP-based search engine to help contact center executives obtain accurate information (which is usually unstructured and is spread across multiple documents) and resolve member queries. This helps to increase agent productivity while reducing the on-hold time.

    4. Next-generation member engagement

Health insurers have long recognized the importance of engaging members to improve the value of care, particularly in the context of traditional care/disease management. Yet efforts to date have rarely achieved the desired impact. However, the promise of member engagement remains throughout the care journey and the underlying capabilities needed to drive impact are rapidly gaining ground — especially data liquidity, advanced analytics, and digital solutions.

    Solution: Predict Members at high risk for Type 2 Diabetes

Advanced analytics enables the swift development of actionable personas (identifiable member segments with distinct known features and preferences) and predicts members who are at-risk of turning diabetic. Analytics can assist in developing personalized messages and interventions and prescribe appropriate medical pathways as treatment. These empower care managers to drive member behavior change and reduce the cost of care.


Understanding the consumer is the driving imperative in delivering care quality, increase member satisfaction, and reduce medical spending. These are all elements of the consumer experience that healthcare has struggled with, and the window of opportunity to retain existing members and win new ones through personalized experiences for legacy brand healthcare organizations is closing rapidly.


We look forward to receiving your feedback. You can send questions or suggestions to contact@abzooba.com.
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