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Challenges for TPAs as call volumes rise?

Updated: Nov 14, 2022

Have you ever wondered why TPAs (Third Party Administrators of healthcare insurance) suddenly experience a spike in their call volumes during certain times of the month or year? There might be a variety of reasons for this to happen. Below are five common issues faced by the TPAs and the reasons why Voice AI could be a solution.

1. Handling Multiple Queries:

In the case of a TPA, an agent handles multiple insurance providers, and it is a fundamental yet big challenge for a single person to remember all the policies by heart. It is time-consuming, as when a caller has a query, it will take a few minutes for the agent to answer the question after referring to all the necessary documents. This, in turn, increases the call queues and wait time of the customers, thus resulting in a spike in call volumes.

On the other hand, the customers expect only plug and play rather than waiting long hours on call. Also, it becomes very tedious for an agent to answer repetitive queries one after the other. Additionally, there are high possibilities of errors.

In this case, Voice AI can bridge the gap between the frustrated customers and the TPA agents, as Voice AI conversations can handle all the basic queries of the customers in a short period. Thus, agents will be required to operate only complicated scenarios. As a result, call volumes can be managed.

2. Unpredictable Calls:

The type of calls in the case of a TPA is very unpredictable as they involve multiple insurance providers. Terms and conditions differ in each policy, be it PSU's retail policy, private insurer's policy, or group insurance policy.

Only a hand full of people are aware of all the available policies; even if they are, not all terms and conditions are clear to them.

AI can significantly help in this scenario by providing all the necessary information to the customers as and when required. Also, it is simple for an AI Voice to fetch and provide all the policy details to the customers, thus providing excellent customer satisfaction and a positive customer experience.

3. New Addition to the Business:

Due to the spike in call volumes, it becomes challenging to manage the call volumes with the help of existing agents. Thus, it becomes essential for the TPAs to hire additional workforce, which is time-consuming because it takes ample time to recruit, evaluate, verify and train the associates for the necessary process. By the time the training process is completed, the work piles up, thus resulting in inefficient management by the TPAs and loss of existing customers.

Due to the high volume of calls, engaging an additional workforce is also very difficult.

This can be avoided by adopting new AI technology, through which monotonous and repetitive queries can be automated and answered by Voice AI; as a result, the call volumes are also efficiently managed.

4. The Transition of Business:

There is a constant change in technology, and we need to adapt to the changing technological needs.

Even the basic queries take a lot of time in the old system. The cost of adapting to the new technology is high and also time-consuming.

Setting up new technology, CRM, and other applications is time-consuming. As a result, the call queues increase. Product training and system training also takes time.

AI can help us to grab new business from our competitors. How? When a new business approaches, it takes a minimum of two months to set up the Customer Care Executive (CCE) and start our business operations. Hiring and training resources and obtaining the necessary certifications also take time. Additionally, the resources need plug-and-play flexibility, and the business needs a BCP in hand so that new clients can start working immediately.

5. Seasonal Call Volumes:

There are certain times of the year when the call volume significantly increases in the case of a TPA. To handle high call numbers, the TPAs will need to adapt quickly and swiftly or risk the danger of frustrating or disappointing customers who may damage the TPA's reputation.

With the help of a Voice AI system, this can be circumvented by providing a timely resolution, improving call quality, and providing customers with a good customer experience. This additionally helps in preventing from swaying away of customers to the competitors.


Although there are multiple challenges faced by the TPAs, adapting a new AI technology helps the customers and the TPA organizations effectively. The prime aim of the TPAs is to improve customer satisfaction and policyholder happiness. This can be achieved without any hassle with the help of AI.

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