A Major Healthcare Solution Provider streamlines claims management with CafeX

In this case study
Key lessons from deploying CafeX at the Healthcare Solution Provider

1. Automate points of contact and workflows to mobilize and manage agents for effective claims handling.

2. Ensure efficient handling of inbound queries by aligning all relevant procedures, claims information and history in dedicated workspaces.

3. Improve decision making and productivity by giving agents access to content and incoming data through robust application integrations.

4. Facilitate seamless communication between agents and subject matter experts by leveraging built-in chat, video, and on-demand screen sharing.

5. Template common inquiry types into workspaces to reduce new agent onboarding time and ensure agent compliance with policy.


A major Healthcare Solution Provider delivers solutions to over three million providers across the entire United States. With a team of about 6,000 people, this company is rapidly transforming its approach to claims management to provide greater accessibility, transparency and real-time control over the claims cycle.

With providers based out of all 50 states, the company had developed solutions and verticalized services to be customized to the claims processing procedure for each state. This meant that an immense amount of knowledge was kept within regional customer service teams so that agents could only process the claims of a provider from a single state where they had expertise, rather than any given provider that called in.

Prior to using CafeX, the company saw the following issues arise in their claims management program:
  • Agents had to access information through state specific systems in order to comply with federal requirements. Due to the nuances in protocol and functionality of each system, the company had to dedicate agents to a single state rather than enabling agents to handle multiple states.
  • Agents were underutilized because the claims management process differed across states in order to follow each state’s requirements. If an agent was untrained in a certain state’s system it caused inconsistencies or delays in servicing providers.
  • Agents had to rely on internal knowledge on how to navigate through systems. As a result, junior agents and even experienced agents who were unfamiliar with a certain claim, lost out on productivity by spending time cross-referencing and querying for data.

The Solution

CafeX optimizes claims management by providing an omnichannel experience between agents and providers. The solution equips agents with information personalized to each claim, and presents it in an intuitive, and interactive way. With CafeX, agents solve claims faster, decrease touchpoints, and reduce back-and-forth communication.

The company reported the following improvements:
  • The single user experience equips agents to handle calls from different states without having to switch between screens, or log into separate systems..
  • Automation proactively guides agents through their calls, accelerating handle times.
  • The Composite API unifies and rationalizes access across multiple systems and states, which makes understanding an incoming claim more intuitive for agents.

CafeX manages claims end to end

By decreasing touchpoints and reducing back-and-forth communication, agents now solve claims faster. The Healthcare Solution Provider reduced call handle time by 35%

CafeX helped the Healthcare Solution Provider deliver fast, quality, cost-effective service. No matter the differences to the type of claim or how the claim develops, the single interface guides the agent through any given call, automating the retrieval of relevant data, and unifying data access to increase overall productivity.

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