This Article provides an overview of how AI Voice Agents can lower call center operating costs and also simultaneously elevate the brand perception and customer service reputation of the health plan or the TPA. These AI Voice Agents can automate routine inquiries like Claim Status, Eligibility Verification and Benefits Inquiries.

Introduction - Why optimize your call center now?

Health Plans and TPAs face intense pressure to lower operating costs. There are several reasons 1) Medicare (& Medicare Advantage) and Medicaid reimbursement rates are going down. 2) Commercial Groups are pushing back on decades of price increases. 3) Lucrative revenue sources like pharmacy rebates are drying up.

There is also an urgent need to elevate the member experience and improve the Net Promoter Score (NPS) . Newer products like level-funded, direct primary care and ICHRAs are directly competing with Health plans and TPAs and member experience is increasingly the source of competitive advantage.

The Answer - AI Voice Agent focused on Health Plans and TPAs

A modern LLM-Powered AI Voice Agent can transform the call center experience. It can answer all the calls received at the call center - whether they are from members or providers. Callers can speak in full sentences with the AI Voice Agent and describe the reason for their call in their own language.

If the call is a routine inquiry like verifying eligibility or getting claims status, an AI Voice Agent can easily engage callers in a conversational experience, provide the answers and complete the call. In order to fully automate or answer these calls, the AI Voice Agents needs to integrate with the Payer's backend systems. These include member and eligibility databases, the CCaaS System and the CRM System.

Also AI Voice Agents is no longer a technology that will only become practical in the future. Unlike other technologies, AI is gaining rapid acceptance and such natural conversational interactions are a reality today. This Generative AI based Voice Agent has already been implemented in some of the fast-moving TPAs and health plans.

Designing the AI Voice Agent to seamlessly handoff calls to Live Agents

Any Health Plan or TPA will want an AI Voice Agent that seamlessly integrates with the phone system or CCaaS platform being used. Modern CCaaS platforms include Five9, Genesys Cloud, Dialpad, Nice CXOne, RingCentral and Avaya.

The AI Voice Agent should be able to transfer a call over the PSTN to the appropriate queue in the CCaaS platform based on the reason for the call. And most importantly, when an Agent actually becomes available and is able to take a call that is transferred by the AI Voice Agent, the Agent should receive a "Screen Pop" of all the information or context of the interaction with the AI Voice Agent. The most frustrating thing from a user-experience standpoint is to design a system or process where the caller has to repeat information that was already provided to the AI Voice Agent.

Improving Productivity of Live Agents with real-time assistance

Even after the call is answered by the human agent,  the AI Voice Agent should continue to monitor and listen to the conversation between the caller and the Live Agent. In other words, it is not sufficient to just provide the context of the caller's interaction with the AI Voice Agent. It is also very important to guide and help the AI Agent in real-time. In order to do this, the AI needs to have access to the real-time audio stream, stream the audio to a Large Language model secured with adequate guardrails. As context, the LLM needs to be provided with internal knowledge-base or support articles as context.

Analyzing and Rating the end-to-end caller journey

After the call is answered by the human agent,  the AI Voice Agent should automatically extract sentiment and key audio and NLU metrics and also score or rate the interaction between the caller and the Live Agent for Quality Assurance purposes.

Are you at a Health Pan or a TPA? Call Casey, our AI Voice Agent today.

If you are at a Health Plan or a TPA? You can experience how  Casey, Voicegain's AI Voice Agent for Payers, interacts with callers in call centers today.

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Here is a link to experience our demo. All it needs is 5 minutes. In-depth instructions to interact with the Demo are provided on the website. 

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Why the Stars Matter

CMS uses the Medicare Advantage & Part D (MA-PD) Star Rating system to steer more than 31 million beneficiaries toward high-quality plans and to decide who receives quality-bonus payments worth billions each year. Contracts at 4-start (★★★★) or 5-star (★★★★★) get marketing benefits, extra rebate dollars, and enrollee growth, while plans that slip below ★★★ can be sanctioned or terminated.

A Quick Primer on How CMS Calculates the Rating

Where Plans Lose Stars

• Member experience & complaints (currently 4× weight): CAHPS scores are sensitive to long hold times, language access gaps, and unresolved grievances.
• Access & call-center metrics: CMS audits interpreter availability, TTY performance, and after-hours answer rates.
• Preventive-care process gaps: Screenings, vaccines and follow-up calls drag ratings if members can’t be reached.
• Medication adherence & MTM: Three adherence measures remain 3× weighted; missed refill reminders hurt scores.

Enter the Always-Available AI Voice Agent

Voicegain Casey, an AI Voice Agent that can maintain and boost CMS Star Rating

Voicegain Casey—launched April 2025— is an AI Voice Agent that handles every incoming provider or member call. It understands the intent of the call, performs HIPAA validation and automates routine inquiries like claims status, eligibility and benefits inquiries. For calls that need live human agent assistance, it transfers calls to live agents with a real-time screen-pop and continues to assist the Agents. It shaves 2–3 minutes of after-call work and boosting CSAT/NPS for health plans and TPAs.

In addition it records and analyzes each and every interaction and flags an interaction that has not met the standard. This can be of immense value to the MA Health Plan.

Implementation Tips for Health-Plan Leaders

1. Start with high-volume intents (eligibility, claim status, pharmacy refills) to free agents for complex CAHPS-sensitive calls.
2. Integrate with your CCaaS & CRM so AI can pre-populate member data and log screenings automatically.
3. Set Stars-oriented KPIs—e.g., hold time < 30 s, outbound reach rate > 70 %, refill reminder completion—to quantify lift.
4. Monitor sentiment & compliance; modern voice AI can redact PHI, track interpreter usage, and surface grievances before they hit CTM.
5. Plan for 2026 weight changes: Even with Patient-Experience weight dropping to 2×, CMS still ties >30 % of Stars to access and experience—so keep delighting callers.

The Bottom Line

CMS Star Ratings increasingly reward real-time, patient-centric service. A 24/7 AI Voice Agent acts as a tireless first-responder—answering every call, closing care gaps, and feeding analytics back to your Stars team. For plans chasing ★★★★ or trying to stay above ★★★, deploying voice AI isn’t just a CX upgrade; it’s a direct lever on revenue-critical metrics.

Get in touch

If this topic is of interest and if you want to see how other health plans are using Voicegain Casey, get in touch with us

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