Insurance Eligibility Verification at Scale: How Health Plans Can Reduce Call Volume and Speed Up Member Access to Care

When a member calls a health plan, they rarely start with a simple question. They’re usually trying to get care scheduled, confirm coverage, understand a denial, or figure out what happens next. At the center of all that sits insurance eligibility.  

When eligibility info feels unclear, outdated, or hard to confirm, people pick up the phone. Call volume climbs, handle times stretch, and member frustration spikes right when access to care should feel easiest. 

For payers, this moment has gotten tougher to manage because service demand keeps rising while benefits get more complex. Digital tools help, but many member journeys still hit a “human needed” wall: plan changes, coordination of benefits, prior auth confusion, provider network questions, and claim status uncertainty.  

The result shows up inside the contact center: more repeat calls, more escalations, and more time spent clarifying things members assumed would be straightforward. 

The good news: eligibility verification at scale doesn’t require a complete reinvention. It takes a tighter operating model that removes friction where calls get created, closes gaps between systems and scripts, and makes member communications feel consistent across every channel, especially for Medicare member services, where speed and clarity matter even more. 

Why eligibility drives calls in the first place 

A lot of call volume comes from preventable uncertainty. Members call when they can’t confidently answer questions like: 

• “Am I covered for this service today?” 

• “Why does my portal show something different than my provider’s office?” 

• “Do I need approval before I book?” 

• “What’s the status of my claim and when will it pay?” 

Those questions blend together. Eligibility touches enrollment, benefits, network status, and often claim processing downstream. So when an eligibility experience breaks, it doesn’t just create one call. It creates a chain: one call to confirm coverage, another to check an authorization, another to ask about claim status, then a complaint when timelines slip.  

That chain often lands inside insurance claims support teams too, because members don’t separate “eligibility” from “billing outcomes.” They just want answers. 

Administrative friction plays a big role here. CAQH has consistently highlighted how much time the system loses on manual workflows. In its 2024 Index key takeaways, CAQH reports that automating claim status inquiries can save medical providers and staff up to 18 minutes on average per patient visit, noting that automation cuts down on phone calls and speeds information flow.  

While that stat focuses on provider-side burden, the implication for health plans stays clear: every manual step creates more inbound questions, more callbacks, and more dissatisfaction. 

The hidden call-volume multipliers: denials, delays, and “now what?” 

Even when eligibility data is correct, it can still produce calls if the experience feels inconsistent. One of the biggest multipliers sits at the intersection of denials and member confusion. 

The American Hospital Association reports that between 2022 and 2023, care denials increased 20.2% for commercial claims and 55.7% for Medicare Advantage claims.  

Denials don’t just impact provider revenue. They generate member anxiety and immediate outreach: “What happened?” “What do I do next?” “Who fixes this?” Those questions don’t land in a single queue, either. They bounce between member services, benefits, and insurance claims support, depending on how the member phrases the issue. 

Prior authorization volume adds another layer of complexity, especially for Medicare member services. KFF reports that nearly 53 million prior authorization requests were submitted to Medicare Advantage insurers in 2024, and that averages 1.7 requests per enrollee.  

Even if a plan runs prior auth efficiently, that’s a massive volume of touchpoints where eligibility, coverage rules, and next-step guidance need to feel crystal clear. If it doesn’t, members call. 

What “insurance eligibility at scale” actually means

Scaling eligibility isn’t just about staffing. It’s about reducing the number of interactions that require a live person, while making the live interactions faster and more accurate when they’re needed. 

At a practical level, eligibility at scale means: 

• Members can self-serve routine coverage confirmation with confidence. 
• Agents can validate and explain eligibility quickly, with fewer system hops. 
• The plan proactively prevents avoidable “where do I stand?” calls. 
• Escalations route correctly the first time, especially across insurance claims support and benefits teams. 
• That requires operational choices across people, process, and technology. 

Here’s what tends to move the needle fastest:

1) Tighten the “first answer” experience across channels 

Members don’t care which channel they used. They care that the answer matches. If the portal says one thing and an agent says another, the plan loses trust and gets repeat calls. 

Start with a simple goal: the most common eligibility questions should produce the same response in three places: 

• Portal or app 

• IVR or chat 

• Agent script and knowledge base 

This alignment matters for insurance eligibility and for Medicare member services, where benefit structures and exceptions can get nuanced quickly. 

A strong approach here includes content governance: one source of truth for benefit explanations, updated on a schedule, with clear ownership. Many plans already have the content, but it lives in too many places. 

2) Reduce “status-chasing” calls with proactive updates 

A large slice of call volume comes from members chasing progress. They’re not calling because they love phone trees. They’re calling because they’re uncertain. 

You can reduce calls by proactively pushing updates that answer: 

• “We received it” 

• “We’re reviewing it” 

• “Here’s what we need next” 

• “Here’s the expected timeline” 

That applies to eligibility-related inquiries and to insurance claims support, where claim status and documentation requests create repeat contacts. Remember CAQH’s point: automation around status inquiries cuts phone calls and saves time. Payers can mirror that concept on the member side with clearer, more frequent notifications. 

3) Build a smarter routing model for eligibility versus claims 

When eligibility and claims blur together, misroutes happen. Misroutes create transfers. Transfers create repeat calls and lower satisfaction. 

A practical routing model uses a few decision rules: 

• If the question is “Am I covered?” route to eligibility and benefits. 

• If the question is “Why didn’t it pay?” route to insurance claims support. 

• If the question is “What do I do next?” route to the team best equipped to explain next steps, often a hybrid queue trained on both benefit rules and claim workflows. 

Even small changes here can reduce average handle time and cut transfers. It also improves the member experience because the first person they reach feels prepared. 

4) Give agents better “eligibility clarity” tools, not more tabs 

Agents don’t need more systems. They need fewer steps. 

High-performing payer teams focus on: 

• A consolidated eligibility view (coverage dates, plan type, network status, key benefit rules) 

• Clear flags for exceptions (COB, recent plan changes, terminations, reinstatements) 

• Script prompts that translate benefit language into member-friendly explanations 

This matters in every line of business, and it’s especially critical in Medicare member services, where members may call with higher urgency and lower tolerance for confusing wording. 

5) Standardize next steps so calls end cleanly 

A big driver of repeat calls: the member hangs up without knowing what happens next. That’s true even when the agent gave a correct answer. 

For eligibility calls, the close should consistently include: 

• A recap in plain language 

• The next step the member should take 

• The next step the plan will take 

• A timeframe, even if it’s a range 

• Where the member can check their status without calling 

For claim-related conversations, this same discipline strengthens insurance claims support performance and reduces callbacks. 

A quick checklist for payer leaders trying to reduce call volume 

If you want a simple way to pressure-test the operation, look at these questions: 

• Can a member confirm insurance eligibility in under two minutes without calling? 

• When a member calls, can the agent see eligibility status and key benefit rules in one view? 

• Do claim status and document requests trigger proactive notifications? 

• Are eligibility and insurance claims support teams aligned on what each queue owns? 

• Do your top 20 call drivers have clear, consistent answers across digital and live support? 

If several answers feel uncertain, that uncertainty probably shows up as call volume. 

Where Liveops can support payers and health plans 

Some health plans solve these challenges with internal redesign. Others bring in Liveops to expand capacity, extend coverage into evenings and weekends, or stay steady through peak-season demand without losing consistency. 

The key: any partner supporting payers has to handle sensitive workflows with precision, especially across insurance eligibility, Medicare member services, and insurance claims support. With Liveops, health plans can add experienced customer care talent, reinforce standardized workflows, and protect quality through clear documentation and escalation paths. 

The goal isn’t simply to answer more calls. The goal is to prevent avoidable calls, resolve complex questions faster, and protect member trust when stakes feel high. 

That’s what “eligibility verification at scale” unlocks with Liveops: fewer unnecessary contacts, faster access to care, and a support experience that feels like a help desk, not a hurdle.