Insurance calls at a medical practice: what can be automated and what cannot

Two kinds of insurance calls at a medical practice can be handled by software on an inbound call today: the "do you take my insurance" question, answered from the practice's own list of accepted plans, and capturing a patient's insurance details at intake. Eligibility verification, benefits questions and prior authorization are different work, done in different systems, and an AI receptionist should route those calls rather than attempt them.

The rest of this post explains why the line falls there and what to do on each side of it.

The insurance calls a medical practice actually gets

When practice managers tally a few days of calls, insurance turns up in more places than the phone menu suggests. It is five or six categories, not one, and each needs different handling.

The top two rows are information the practice already holds or the patient already knows. The bottom four need a lookup against a payer, a judgment about coverage, or knowledge of a specific claim. That is the line, and it is a sensible one rather than a technical limit that will vanish next quarter.

How should a practice answer "do you take my insurance"?

From a specific, current list of accepted plans, with a reminder to confirm with the insurer. It is one of the most common calls from people who are not yet patients, which makes it one of the most valuable to answer at 7pm on a Tuesday. A caller who cannot find out whether you take their plan calls the next practice that picks up.

MedPhone answers accepted plan questions from the practice's configuration, the same way it answers hours, location and parking. The answer is only as good as the list, and most practice lists are written at the wrong level.

• Name plans, not just carriers. A practice can be in network for one product from a large carrier and out of network for another from the same carrier. "We take Aetna" is the kind of answer that produces a surprise bill
• Decide what happens when the answer is no. Is the caller offered an out of network appointment, or told the practice cannot see them? Settle it once rather than leaving it to whoever answers
• Tell the caller to confirm with their plan. Even a correct list cannot capture every variation in a patient's coverage, and an honest answer says so
• Keep the list current. Contracts change, often at the start of the year. A stale list on an AI agent is wrong on every call at every hour, which is worse than a stale list in one receptionist's head

Insurance intake on the call

The second call software can finish is the patient whose insurance has changed, along with every new patient whose insurance needs recording before the first visit. The work is collecting the same handful of details every time: tedious for a person, consistent for software.

MedPhone captures insurance information at intake, and on athenahealth it matches those details against the patient record and flags anything that does not line up for staff review. A changed plan is caught before the visit, rather than at the window or on a rejected claim.

The value is timing. Many patients change plans at the start of the year, and the front desk usually finds out one check in at a time. Capturing the change when the patient calls to book moves that discovery days earlier, which gives whoever does verification time to do it properly.

Why insurance verification calls need a different system

Capturing insurance details is not the same as verifying them, and this is where vendors in my category most often blur the language. Intake records what the patient says. Verification asks the payer whether that coverage is active and what it covers, and gets an answer back.

Eligibility and benefits checks run as a standard electronic transaction between provider and health plan, one of the transactions set under HIPAA administrative simplification. In practice they go through the practice management system, a clearinghouse or a payer portal, often in a batch the day before appointments. When a response is unclear, somebody on staff calls the payer and waits on hold.

MedPhone does not do eligibility verification. Its job is to capture the details verification needs, accurately and early, and to get a patient with a coverage question to the person who can look it up. If a vendor says its phone agent verifies eligibility, ask what system it queries, what it does with an ambiguous response, and what the patient is told. Then ask to hear one of those calls.

Prior authorization calls

Prior authorization generates calls in both directions. Patients call to ask whether their MRI, procedure or medication has been approved. Staff call payers to submit, chase and appeal. The AMA has campaigned on prior authorization burden for years, because of the practice time it consumes and the care it delays.

Some relief is arriving on the payer side. Under the CMS Interoperability and Prior Authorization Final Rule, impacted payers, including Medicare Advantage plans and Medicaid and CHIP programs, must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, starting in 2026. That shortens the wait. It does not remove the calls.

An AI phone agent should not touch the authorization itself, and MedPhone does not do prior authorization. What it can do is recognize a status call and transfer it, with the patient identified and the question stated, to whoever owns authorizations at the practice. At a specialty practice, where procedures often cannot be booked until an authorization clears, that routing is most of the value.

What changes when routine insurance calls come off the desk

The point of automating the top of the table is not that those calls are hard. It is that they are frequent and they land during check in, when the person at the window is already holding an insurance card in one hand.

Of the 10 to 15 front desk hours a week we estimate Synergy Medical has gained since going live on athenahealth, insurance intake is a part, not most. Scheduling, rescheduling and refills account for more.

In practices that do this well, the hours go where the bottom of the table needs them: verifying the next day's schedule properly instead of at the window, and following up the authorizations that would otherwise stall. The phone agent takes the information. People do the insurance work.

See what MedPhone costs at your call volume

Questions people ask

Which insurance calls at a medical practice can be automated?

Two kinds: answering whether the practice accepts a caller's plan, from the practice's own list, and capturing a patient's insurance details at intake. Eligibility verification, benefits questions, prior authorization status and billing questions need a payer lookup or a person, so a phone agent should route them with context.

Can an AI receptionist verify insurance eligibility?

MedPhone does not. It captures insurance details on the call and, on athenahealth, flags anything that does not match the record for staff review. Eligibility verification is a separate electronic transaction with the payer, usually run through the practice management system or a clearinghouse.

How should a doctors office answer "do you take my insurance"?

From a list of accepted plans the practice keeps current, naming plans rather than just carriers, with a suggestion that the caller confirm with their insurer. A confident yes based on the carrier name alone is how patients end up with surprise out of network bills.

Can AI handle prior authorization calls?

It can route them, not resolve them. MedPhone does not do prior authorization; it recognizes a patient calling about authorization status and transfers them, already identified and with the question stated, to the staff member who handles authorizations.

What insurance information can an AI receptionist capture?

The details staff need to verify coverage, such as the carrier, the plan and the member ID, taken during the call. On athenahealth, MedPhone matches them against the existing record and flags anything that does not match for staff to review before the visit.

Why do insurance calls spike in January?

Because many patients change plans at the start of the year, and the practice usually finds out when they book or check in. Capturing the change when the patient calls to book, rather than at the window, gives staff time to verify the new coverage before the visit.