Demystifying Healthcare Insurance

Photo_Mike Semick.jpg

Michael Semick

Chief Technology Officer

Client's Business Goal:

Every day customers interact with their benefits, from routine visits to their primary doctor to a “Moment of Crisis” like an ER visit. No one will argue that the healthcare system is not complicated. Personal benefits are also very complicated and outside of picking up a phone and calling customer service, it’s not clear how one can easily get answers. The web has made many things easy to digest and understand, but unfortunately healthcare benefits are not one of them. The business goals were to:

  • Illustrate how to improve Customer Experiences by simplifying Customer interactions and accessibility. Ease customer access and understanding if their benefit information. Health Insurance companies need to make benefits information more accessible, and provide more self-service for consumers to reduce customer reliance on Customer Service to interpret their benefits.
  • Transform complex benefit information so it can be used in a service architecture to serve multi-mode consumer facing applications including conversational interfaces.


Prime 8's Solution:

We designed and and built a system to allow a health insurance company to input and manage Benefit Book related language in a single location as a single source of benefit language. The system focuses on supporting Customer Service and and the Enterprise Customer population. The system supports complex constructs and links multiple use specific variations of taxonomy to a common core of required legal language including:

  • An Ingestion mechanism for existing benefit data.
  • A flexible, elegant User Interfaces for Customer Service, web and mobile.
  • Supports connectors (API's) to other business systems.
  • A multifaceted, rules based, flexible, extendable knowledge base, that can expand to enterprise scale.


The Business Impact:

  • Deconstruction of Benefit Book: articulated the book logic and core concepts, understanding of the variables to build associated data grids, analysis of Plan structure, and modeling of concepts for the solution.
  • Deployed a "Single Source of Truth" for expressing Consumer Benefits.
  • Reduce confusion and benefit errors for the business and consumer.
  • Customer Service and Customers can center on using one tool to quickly answer the most common benefit questions; Using a simple and intuitive interface, Customer Service agents would query the knowledge base for targeted answers and information.
  • Reduced training time.
  • Decreased call times.
  • Increased Member satisfaction with customer service.