In the intricate machinery of the U.S. healthcare system, the call center remains one of the most overlooked components. For payers, it is where members go for answers about their benefits, and where providers turn to resolve issues that often sit between care delivery and reimbursement. These call centers are the first and sometimes only human touchpoint in an otherwise impersonal system.
And yet, most are falling short. Handle times are too long. Wait times stretch patience thin. Agents are overwhelmed by repetitive questions. Many systems remain outdated, disconnected, and difficult to navigate. The call center, in many ways, reflects the larger system it serves: overburdened and struggling to keep up.
Call centers within payer organizations typically operate on multiple tracks, with the two primary ones serving members and providers. While both are grounded in service and resolution, their goals often diverge—reflecting the unique needs of each audience. From benefit clarifications to claim disputes, and even appeals and grievances, these call centers are the frontline of interaction with the health system.
Members call to ask about benefits, ID cards, eligibility, prior authorization, and claims. These questions can be personal, urgent, or simply confusing. Providers call for a different reason as they are often trying to understand why a claim was denied, confirm whether a patient is covered, resolve credentialing issues, or interpret reimbursement policies.
These two sides reflect the dual responsibilities of a health plan. Supporting individuals and managing relationships with the physicians and hospitals who care for them. Yet in practice, both sides face similar frustrations. They are routed through outdated systems, put on hold for too long, and passed between departments that do not share data in real time.
The Numbers Behind the Noise
Call center performance can be measured in several ways, but a few metrics matter more than others. Average handle time, or AHT, tracks how long it takes an agent to resolve a call. Many payer organizations see this number exceed 10 minutes for provider call centers, often due to clunky internal systems or lack of access to clear information. A target under 8 minutes is ambitious but possible with the right design. Healthcare call centers report an average speed to answer of over three minutes, markedly longer than the 28-second benchmark seen in other sectors. 1
Another critical metric is average speed to answer, known as ASA. This measures how quickly a call is picked up. A benchmark under 30 seconds is considered best in class. Yet for many Payers, this standard is consistently missed, especially during high volume periods.
Repetition remains a persistent challenge. Many providers call with the same set of routine questions—questions that, in a more modernized system, might easily be addressed through self-service tools or clearer communication channels. In the absence of such infrastructure, the responsibility inevitably shifts to the call center, adding strain to an already overburdened system.
A Different Approach to Fixing the System
Improving call center operations requires more than simply adding staff. It demands clearer systems, smarter tools, and a sustained commitment to removing the friction points that slow everything down.
The first line of defense against overwhelming call volumes lies in the tools available to providers and members long before they ever pick up the phone. A well-designed provider portal—with intuitive search functionality, real-time claim status updates, and clearly written answers to frequently asked questions—can preempt many of the most common inquiries. For members, a secure app or website that allows them to view benefits, download ID cards, and check prior authorizations can offer the kind of immediate clarity that makes a phone call unnecessary.
Beyond portals and apps, a significant share of call volume could be reduced through thoughtful automation. Intelligent chatbots—trained on actual call transcripts and capable of understanding natural language—can address routine questions without the need for human intervention. When designed with care, these tools don’t just deflect calls; they create a smoother experience, offering timely answers while ensuring a seamless handoff to a live representative when the issue calls for it. Another way to support agents in accessing information more efficiently is through AI-powered solutions that can quickly synthesize documentation and surface relevant details in real time.
For the calls that inevitably make it through, efficiency at the agent level becomes critical. That starts with reducing screen clutter, streamlining systems, and providing a centralized, up-to-date knowledge base that’s easy to navigate under pressure. Too often, it’s not the agents who are slow—it’s the systems around them. The most effective improvements often come from redesigning how agents access information, not from pushing them to move faster.
Call routing, too, plays a quiet but essential role. When calls are directed based on issue type and agent expertise, resolution becomes both faster and more accurate. A representative trained in provider credentialing, for instance, shouldn’t be fielding questions about pharmacy benefits. And members reporting a billing error shouldn't have to navigate a general queue. Skill-based routing ensures that callers reach the right person the first time—minimizing frustration and maximizing efficiency.
During peak hours, even the most well-designed systems can be stretched thin. Offering callers the option to receive a callback—a small but meaningful feature—can ease frustration and reduce the number of abandoned calls. It also gives agents more flexibility to manage their workload, ensuring that when the call does happen, it’s not rushed or reactive, but focused and helpful.
Finally, consider how often a problem could have been prevented with a proactive call. If a provider submits claims with the same error week after week, a five-minute outbound call from a dedicated team can solve it. If a member misses a key deadline, a reminder text or email could prevent confusion later. Proactive outreach is often underused, but it is one of the clearest ways to reduce future call volume and build trust.
What a Better Call Center Looks Like
What does a better call center look like? It is structured, seamlessly integrated, and equipped to empower agents rather than encumber them. It anticipates common questions and diverts them through self-service or automation. And when a human touch is required, the response is prompt and informed. Call centers that consistently achieve first-call resolution rates above 72 percent rank among the industry's top performers.2
This is not an unreachable vision. It’s a matter of focus and follow-through. When payers invest in their call centers, they’re not merely addressing a customer service concern—they’re strengthening the infrastructure that supports the delivery of care itself. People call their health plan when they are confused, anxious, or out of options. These calls aren’t just transactions; they’re a window into the health system’s reliability. They deserve to be met with the same care and attention we expect from every other part of healthcare.
Feel free to reach out to Mizzeto’s team if you're interested in learning more about how we can help improve your call center operations and key performance metrics.
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