Three thousand calls a month. One in four answered.
Hospital billing teams called about claim status and got voicemail. Two weeks of disposition analysis showed where the calls went, why claims were denied, and which answers already lived in the client's own systems.
What the transcripts said
Seven in ten provider calls went to voicemail. Every one became a callback, a chased email, or a claim aging in the queue.
Dispositions tagged by intent and outcome: claim status, appeals, denial questions, eligibility, and the callbacks each unanswered call created.
Denial reasons clustered by root cause. The largest single share needs an eligibility endpoint that does not exist yet, which set the build order.
Every system a specialist touches to resolve a call, traced to the API surface an agent can use, and the endpoints the client's engineers would need to build.
Where the calls actually go
- Claim status lookups45%Status, amount paid, check run date: answerable from live data
- Denials & appeals25%Reconsiderations that used to require a callback
- Eligibility questions15%Blocked on a patient-data endpoint; interim ticket flow
- Claims not on file10%A verification loop, then a structured ticket
- Everything else5%Misroutes, one-offs, edge cases
Share of inbound volume by intent, from disposition analysis; proportions approximate. Before the engagement, seven in ten of these calls were never answered at all.
The systems map
- Claims data warehouseClaims
- Patient data platformEligibility
- API gatewayIntegration
- CRMCase management
- Telephony platformCalls
- QA & call monitoringQuality
Systems genericized here for confidentiality. The real investigation deliverable names each one, with owners and endpoints.
From investigation to production
- Week 1Ingest and map
Call dispositions analyzed, denial reasons clustered by root cause, resolution flows charted with the claims lead.
- Week 2Build plan agreed
Claims API scoped with the client's engineering team; coverage first, resolution second, sequenced by measured volume.
- Weeks 3–4Every call answered
Intake workflow live: each call captured as a structured case in the CRM. Coverage goes from one in four to 100%.
- Weeks 5–8Live claim lookup
Callers authenticated against live claims data; status, amount paid, and check run date read back on the line. Deflection measured from day one.
- Weeks 9–12Appeals and denial flows
Reconsiderations filed on the call with case IDs written back; denial-specific scripts ship; multiple matching claims narrowed by billed charges.
- Week 13+Operate
Denial-response flow in UAT, eligibility endpoint scoped with the client's engineers, deflection at 23% of all calls and climbing.