Claim Integrity
Identify the agent errors creating downstream claim denials
Find the patterns in your contact center driving billing rework, so you can coach them out instead of absorbing the cost.
Healthcare · Contact Center Intelligence
Every member call carries a clinical and financial signal. Most health plans hear neither.
Payers and providers run millions of calls a year — prior authorizations, benefit questions, billing disputes, care outreach. The intelligence inside those conversations decides Stars ratings, medical loss, and whether a member gets care. Spearfish surfaces it across 100% of interactions.
◆ Voice · Chat · Message
◆ Payers · Providers · TPAs
◆ 100% call coverage
Live · Prior Authorization
CALL #HC-5520
A
Your authorization for the imaging is still pending clinical review — it can take up to 72 hours.
M
My doctor said it was urgent. This is the fourth time I've called and no one can tell me anything.
A
I understand. I'll add a note and you'll hear back once it's reviewed.
M
So I just wait? I'm supposed to have this done before my surgery.
Care Delay Risk
High 0.81
High 0.81
Repeat Contact
4th +300%
4th +300%
Grievance Risk
Rising 0.76
Rising 0.76
The Problem
The signals that decide care and cost never leave the call.
QA reviews a 1–3% sample to coach agents. In healthcare, the other 97% is where care delays, grievances, and quality risk are hiding — invisible until they surface as an appeal, a Star rating drop, or a member who didn't get treatment.
Before Spearfish
- ✕You know the benefit was explained — you can't tell the member hung up still confused about what was covered.
- ✕A prior-auth delay looks routine in the queue — until it becomes a delayed surgery and a grievance.
- ✕Stars and CAHPS arrive once a year. By the time scores drop, the interactions that caused it are long gone.
- ✕UM, care management, and quality never hear the call — the intelligence stays trapped in the contact center.
- ✕Your best care advocates leave, and the behaviors that kept members engaged walk out with them.
With Spearfish
- ✓Comprehension is measured separately from delivery — you know the member confirmed understanding, not just that benefits were recited.
- ✓Care-delay risk is flagged in the authorization call itself, and routed to the UM team that can fix the process.
- ✓Star and CAHPS drivers — getting care, getting information, customer service — are tracked continuously, not annually.
- ✓Root causes reach UM, care management, quality, and appeals — the teams who own the fix, not just the queue.
- ✓Winning advocate behaviors are extracted and encoded — every agent performs like your best, from day one.
Use Cases
Built for how payers and providers actually operate.
Four places where contextual intelligence finds what your QA program can't — and turns it into coaching, not absorbed cost.
Quality
Score patient-sensitive interactions on what actually matters
Move beyond tone and AHT to the substance of the conversation your QA program is missing today.
Escalations
Surface the escalations that should have happened but didn't
Build coaching programs around the patterns your current QA can't detect.
Downstream Handoffs
Validate that downstream teams got the information they need
Audit whether billing details, clinical context, and care coordination notes are being captured accurately.
Contextual Metrics
Intelligence your dashboards have never produced.
| Metric | Scope |
|---|---|
| Benefit Comprehension Rate | Per call type |
| Care Delay Risk Score | Pre-authorization |
| Care Advocate Empathy Score | 100% coverage |
| Grievance Risk Score | Pre-complaint detection |
| Sentiment Trajectory | Call arc, not snapshot |
| True Resolution Rate | Outcome, not code |
| CAHPS / Stars Driver Signal | Continuous, not annual |
Traditional analytics tell you what happened — the call lasted 9 minutes, was marked resolved, the authorization status was read aloud. Contextual intelligence tells you what actually happened: the member was confused and frightened, the delay is about to postpone a surgery, and you have a grievance — and a Stars hit — you could have prevented.
Spearfish Whitepaper — What is Contextual Intelligence?
How It Works
Deployed in days. Results from day one.
Spearfish sits on top of the contact center and clinical systems you already run — without replacing anything.
Works with
Genesys
Five9
NICE
Talkdesk
Amazon Connect
⇄
Connect your stack
REST API integration with your CCaaS, CRM, and where applicable core admin, UM, and eligibility systems. No rip-and-replace, no new data collection infrastructure. Connect what you have.
✎
Define what matters in plain English
Describe what you want to measure — "Did the member confirm they understood the authorization status and next steps?" — and Spearfish applies it to every interaction.
◈
Get intelligence across 100%
Contextual meaning extracted from every voice, chat, and message — sentiment trajectory, care-delay and effort markers, comprehension, and advocate behavior — scored against your standards.
➤
Route intelligence to the owner
The fix reaches UM, care management, quality, or appeals — not just the team running the queue. Leading indicators surface weeks ahead of CAHPS and grievance data.
Compliance & Quality
Regulator-ready evidence. Not just scripts.
★
CMS — Stars & CAHPS Quality
Track the member-experience measures behind Star ratings continuously — getting care, getting needed information, customer service — and act on the calls dragging them down before the annual survey locks the score in for the year.
⚕
HIPAA — Privacy & Data Handling
Enterprise-grade encryption for data in transit and at rest, with a full compliance framework built for PHI and healthcare data requirements. Your data stays yours — Spearfish surfaces the intelligence; you own and control the underlying interactions.
⬡
Appeals & Grievances Monitoring
100% call monitoring means every grievance-adjacent interaction is evaluated, flagged, and logged — available for review or audit. Pre-grievance signals are caught while intervention is still possible, not after a complaint is filed.
◊
NCQA — Consistency & Equity
Measure whether members receive the same quality of explanation, empathy, and resolution across all segments. Contextual intelligence surfaces disparities in service quality before they become accreditation or health-equity exposure.
Get Started
Hear what your members have been telling you.
Connect your existing recordings and systems. Get actionable intelligence in days, not months.