All use cases

Collect / Recover

Patient-billing collections and payment plans

A patient just got a bill they don't understand for a visit weeks ago — the next call decides whether they pay it, ignore it, or lose trust in the practice.

Get aheadNext best thingClose the loopRisk triggerTime-based triggerSystem triggerVoiceSMSEmailChatHealth & Telehealth

What it does

Patient balances are the hardest money in healthcare to collect and the easiest relationship to damage. The statement arrives long after the visit, the patient can't tell what insurance covered from what they owe, and a scripted dunning call about a medical bill reads as cold at exactly the wrong moment. The agent runs compliant patient-billing outreach that leads with the explanation: what the charge was for, what the plan paid, and what's left — then offers a same-day payment or a structured plan, and surfaces financial-assistance options where the patient qualifies. It also takes the inbound billing questions with the full account in front of it, so a confused patient gets an answer instead of a queue. The agent orchestrates everything up to a secure payment hand-off; the payment itself always happens on the provider's own hosted step, and card data never passes through the conversation.

How it works

  1. 1
    Trigger. a patient balance ages past its threshold — a statement unpaid after the grace window, a broken payment promise, or a payer-adjudication event that leaves a patient-responsibility amount — or an inbound billing question arrives on any channel.
  2. 2
    Decision. the agent reads the account — the balance, what the explanation of benefits attributed to the patient, prior statements and promises, plan-eligibility and financial-assistance flags — and checks contact windows, frequency caps, and the disclosures medical-billing rules require; a judge gates every outbound contact before it goes.
  3. 3
    Action. an outbound call or message opens by explaining the charge and the insurance split in plain language, then offers the resolution menu — settle today through a secure payment link to the provider's hosted step, set up a plan that fits the household, or start a financial-assistance application where the patient qualifies. Each commitment is captured with an amount and a date.
  4. 4
    Follow-through. plan reminders are scheduled before each due date; kept and broken promises are tracked; a dispute over a charge or a clinical question routes to billing or clinical staff, never answered by the agent; if the balance clears on its own, pending outreach is cancelled; every contact, disclosure, and commitment writes back to a full audit trail.
Example
AgentHi — this is about the statement for your visit last month. Your insurance covered most of it; what's left is $84 for the lab work, which didn't fall under your copay. I can take that today on a secure payment page, or split it across three months if that's easier. Which would you prefer?
CustomerI didn't realise the labs weren't covered. Money's tight this month.
AgentCompletely understandable — let's spread it. Three payments of $28, the first today, the rest on your usual date. If things are tighter than that, you may also qualify for our financial-assistance program, and I can start that for you instead. Just say the word.

Configuration

How the agent is wired for this use case.

Triggera patient_balance_overdue event from the billing system after the statement grace window, a payer-adjudication event leaving patient responsibility, or an inbound billing question on any channel.
Tools & actions
  • Billing platform · verify the patient, retrieve the balance, statement history, and prior promises; write back the payment, plan, or assistance application.
  • Claims / EOB system · read the explanation of benefits to state what insurance covered and what the patient owes, in plain language.
  • Payment provider · hand off to the provider's secure hosted payment step for a same-day payment or a plan's first instalment (the agent never touches card data).
  • Payment-plan engine · set up a structured plan within policy and schedule reminders before each due date.
  • Knowledge base · surface financial-assistance eligibility and start the application where the patient qualifies.
  • CRM / audit log · record every contact, disclosure, and commitment for the compliance trail.
Autonomyexplanation, eligibility checks, and plan setup run unattended under judge gating; the payment is a money-moving policy class completed only on the provider's hosted step; any clinical question or charge dispute is out of policy and hands off to staff — the agent gives no medical or coding advice.
Channelsvoice · sms · email · chat
Escalationa disputed charge, a clinical question, a hardship or vulnerability signal, or a request outside billing policy hands off to billing or clinical staff with the full context.

What you need

The inputs this use case runs on. Your channels stay yours; the agent supplies the judgment.

Signals

patient-balance-overdue events and days-past-statement thresholds, payer-adjudication events leaving patient responsibility, broken payment promises, inbound billing-question events.

Data

patient balance and statement history, the EOB split between insurer and patient, prior promises and plans, financial-assistance eligibility, contact-window and consent preferences.

Guardrails

medical-billing collection rules encoded as policy — contact windows, frequency caps, required disclosures; identity verification before any account detail is shown; judge gating on every outbound contact; the agent gives no clinical, coding, or coverage-determination advice and routes those to staff; payment completed only on the provider's hosted step; stale-outreach cancellation when the balance clears; a complete audit trail.

Metrics it moves

  • recovered-revenuepatient balances resolve as same-day payments or kept plans instead of aging into bad debt and external agencies.
  • conversion-rateexplaining the insurance split before asking for money turns more billing contacts into a payment or a plan than a cold dunning script.
  • csata patient who understands the charge and is offered a plan or assistance keeps trust in the practice, the difference between collecting the bill and losing the patient.

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See it on your own customer journey

Bring one drop-off, one churn cliff, or one silent segment. We will show you what a proactive agent with memory and judgment does with it.

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