The hidden cost of member confusion

Summary

Member confusion isn’t your typical line on a budget sheet, but the trickle down effects from confused members are driving higher costs. 

• When members can’t easily understand coverage, care options, or costs, confusion turns into avoidable call volume, repeat interactions, and higher cost-to-serve.
• Without personalized direction, members default to expensive channels—like call centers and ER visits—driving up both service and claims spend.
• Adding more portals won’t solve the problem; plans need AI-powered orchestration that explains benefits clearly, guides care decisions, and clarifies claims proactively.
• By resolving confusion upstream, health plans can reduce unnecessary volume, improve appropriate utilization, and transform cost into competitive advantage.

Where confusion becomes cost

Health plans invest heavily in benefits, networks, and negotiated rates. Yet a quieter cost continues to rise alongside those investments: member confusion.

Confusion about what’s covered.
Confusion about where to go for care.
Confusion about what something will cost—or whether a bill is final.

These moments don’t just frustrate members. They create avoidable operational costs, drive inefficient care utilization, and push work into some of the most expensive parts of the organization—especially call centers.

And in most cases, the issue isn’t missing information. It’s missing an intelligent orchestration layer to guide members through episodes of care.

When information exists, but members can’t find it 

Most health plans already provide members with plenty of information:

• Benefit summaries and explanations
• Provider directories
• Claims updates and EOBs

But that information is often:

• Fragmented across tools and vendors
• Difficult to find and understand
• Rarely personalized to a member’s situation

Members are left to connect the dots themselves—often across benefits, care options, and financial responsibility—in moments when they’re already stressed or unsure.

So they don’t guess. They call. They ask AI.

This gets expensive—fast

Confusion-driven calls share costly  patterns:

• High volume—on average, healthcare call centers experience about 2,000 calls a day
• Long handle times—The average hold time in healthcare call centers is 4.4 minutes, which is over 5x longer than the 50-second benchmark
• High repeat rates, resulting in low first call resolution (FCR)—healthcare call centers average a 52% FCR
• Frequent escalations—Nearly 1 in 5 healthcare calls are transferred to another agent, reducing FCR and member satisfaction

Call center agents aren’t just answering questions—they’re translating benefit language, explaining healthcare terminology, walking through care options, and clarifying claim status.

In effect, the call center becomes the default translation layer for members—resolving confusion reactively, one interaction at a time. As membership grows, this model doesn’t scale efficiency. It scales your costs.

Statistics sourced from Dialog Health. (n.d.). Healthcare call center statistics. Dialog Health.

The care-setting problem hiding in plain sight

One of the most expensive breakdowns shows up when members are trying to decide where to go for care.

With options ranging from primary care and urgent care to virtual visits and ERs, members often lack clear, personalized guidance on:

• Which setting is appropriate for their situation
• What their plan covers
• What they as the member will ultimately pay out of pocket

So a bad rash turns into an ER visit—followed by billing questions around high cost, claims confusion around different levels of care, and ultimately more calls. This isn’t a failure of members. It’s a failure to navigate the system. Members need intelligent orchestration that guides them to critical context and information to address their specific needs.

Benefits and claims aren’t self-explanatory

The same pattern applies to benefits and claims.

Terms like deductible, coinsurance, and out-of-pocket maximum aren’t common knowledge. Claims and EOBs often provide facts without meaning or clear next steps.

When members can’t confidently answer:

• “Is this covered?”
• “How much will I owe”
• “Does my deductible apply?”
• “Will I have a copay or co-insurance amount?”

Uncertainty compounds and drives more calls. What if instead, they could simply ask an AI Agent?

Why digital experience—not more tools—matters

This problem isn’t solved by more portals or more documents on top of an already fragmented foundation.

A better member experience is dependent on intelligent orchestration across a member’s journey—meaning they can get the information they need, when they need it, and without needing to call or search online for help.

That means:

• Directing members to the right care at the right time
• Explaining benefits and costs in plain language
• Clarifying claims and next steps before confusion turns into calls

When guidance is delivered proactively and consistently via orchestration and support from AI Agents, confusion is addressed upstream—reducing absorption downstream by the call center.

The operational upside

Reducing confusion-driven calls does more than lower volume.

It frees service teams to focus on the interactions that truly require human judgment and empathy—while reducing cost to serve, supporting appropriate utilization, and improving member trust, satisfaction, and retention.

Health plans already orchestrate member experiences today—albeit unintentionally and manually. The opportunity is to make that orchestration intelligent, proactive, and digitally scalable.

Address member confusion head on

Every confusion-driven call is an avoidable cost. Let’s discuss how to resolve calls upstream—before a member even thinks to pick up the phone.

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