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December 31, 2008

Blue Cross Blue Shield of Massachusetts -- can robocalls be human?

by Josh Bernoff

It's amazing how the world looks different once you think that people should be treated as humans.

I said I would call out examples of companies behaving in a way that is not as human as it should be. But companies are made of humans, too, and have objectives. So I will present the company's point of view as well, so we can discuss what ought to happen.

Blue_cross_blue_shield_ma The call

On Monday I got a call from a machine. The recorded voice said this, basically:

Blue Cross Blue Shield of Massachusetts needs some information from you about your health insurance. This call is for Joshua Bernoff. If you are this person or the spouse of this person, please press 1.

OK, I'm thinking a few things now.

  • Why is my health insurance company calling me? Are my benefits in danger? Do I owe somebody money? Is someone hurt?
  • I don't like getting calls from a machine, especially one that demands I answer questions.
  • How can I be sure this is really my insurer and not a scam of some kind?

So, of course, I pushed 1 and got connected to a woman who asked what other insurance I have. When I asked why, she provided the unhelpful answer "Coordination of benefits." That sounds like something that helps them, not me. Eventually she admitted this was voluntary, and I hung up. I am resistant to giving out information about my health to people who call me. Aren't you?

The company's side

I talked with, Tara Murray, a spokesperson for BCBS of Mass. She told me that Blue Cross needs to know about who has Medicare and situations (as when both parents of a child work) where a person can be covered by more than one type of insurance. Why? First, if they bill when Medicare should be paying, this is a violation and they get penalized by the government. And duplicate payments to health care providers drive costs higher.

According to BCBS of Mass., they start by sending letters, which generates 50% responses. These automated calls have added another 20% responses, and cost less (of course) than actual people calling. "Not everybody loves the calls," explains Tara, "but they seems to be helpful in getting the increased response rate, and helpful in the goal of keeping costs down, for members and for ourselves."

Also, after reviewing a draft of this post, Tara responded with this: "[A]fter we talked about your recommendations, the business owner was provided your feedback and he noted that he is going to look into how to improve communicating the goal and the benefit to the member." At least they are open to improving.

Are they treating me like a human?

No. Robocalls from your health insurer don't qualify as treating me like a human. Neither does asking for information without providing a good reason.

While I recognize what BCBS of Mass. needs here, that's only because I took the time to call their spokespeople. Most people won't understand what's going on here. The insurer runs the risk of a backlash including blog posts like the one you are now reading.

I feel that companies must use robocalls very carefully. When my pharmacy generates an automated call to tell me that my prescription is ready, that's good. When my dentist's office calls to remind me of that I'm due for a cleaning, I guess that's ok, since I know him. But a health insurance company trying to coordinate benefits? Doesn't pass the test.

My second suggestion is that the company be explicit about why it is collecting information. "We need to know if you have medicare or are covered by another policy, to avoid duplicate payments and keep our rates low," might be better than "Give us your information for coordination of benefits."

Finally, what prevents them from communicating by email instead of interrupting what I'm doing? "I'm calling from Blue Cross Blue Shield" commands immediate attention, since a call from your insurance company sounds medically urgent. Instead, they are collecting information for their own benefit. An email is far less interruptive and more appropriate for this sort of thing. Is there some regulation against insurers collecting their subscribers' emails, or against employers providing them?

The medical world is inhuman enough already, and so is the insurance world. Blue Cross, please stop the robocalls and treat me like a human.

Blog readers, what's your opinion?


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Jeff Stolarcyk

A few points: As odious as robocalls can be, this seems like it's one of the better-scripted ones. It identifies itself early, is personalized (to the degree that a robocall can be) and delivers you to a live person. I think the communication broke down when you had to deal with the actual human on the other end of the line - likely because the CSR that you spoke with doesn't work for BCBS, but for an out of house call center provider, and thus is undereducated about what they're doing and encouraged to keep to the script they're given (with its filtered-through-legal-and-PR language) who get that "coordination of benefits" sounds official and succinct but blithely ignore that it's totally obfuscatory.

As to the question of "why call instead of email?" one of the core areas they want to identify is benefits overlap with Medicare. Demographically speaking, the telephone is the best way to target Medicare recipients (and this is borne out by the increased response). It's annoying, but they're fishing where the fish are, and it's working for them. Now, could it work better? Absolutely, and hopefully the communication between BCBS and their call center vendor isn't so heavily bureaucratized that this can't be changed.

I don't know; I toiled in a call center for years while I was in school (Frederick's of Hollywood, of all places), so I sympathize.

Jen Chiu

Wow, how annoying.

I think BCBS can get away with this because:
(1) It is difficult as an individual to switch health insurance companies
(2) Consumers are willing to deal with small annoyances when the overall issue is a big deal

I get my health insurance through my employer, so in order to switch providers I first would have to convince the HR department (generally not big fans of change). In order to convince them, I'd likely need to put effort into finding out how many other annoyed employees are out there and mobilize them to complain with me. Big pain, unclear reward.

BCBS was my health insurance company at my old job. Everything major ran smoothly for me, and I liked the bonus check I got to pay for my gym. If I had gotten an annoying robocall from them, I would be annoyed, but complaining wouldn't seem worth it given everything I cared most about was working properly. I'd be worried that the alternatives would actually leave me worse-off.

That said, if other companies started doing similar annoying robocalls, I'd be much more likely to switch just because I was annoyed (consumer products, etc.)

Jenn O'Meara

There are definitely better ways to aggregate this information.

First, the health insurance industry tends to uses terms that do not resonate with consumers. Case in point - how the BCBSMA represenative called the person who managed this project a "business owner." Insurance companies should be actively communicating what double-coverage is. Perhaps some individuals may not even realize they have double-coverage.

Due to HIPAA, insurance companies have been slow to embrace utilizing member web portals. If a vast majority of members were encourage to create a web profile through BCBSMA's website, this information could have been shared through the Member home page or through email communications.

Additionally, BCBSMA could have coordinated with their employer groups (since a vast majority of their business consists of people covered through employees). Employers are looking to lower their overall insurance costs and they will actively work with insurance companies. Who knows - perhaps situations such as double-coverage might ultimately cause premiums to increase. An employer's Benefits Administrator could notify employees that they need to contact BCBSMA. An alternative - BCBSMA could ask for this information each year when employees sign-up (or renew) during open employment.

Robo-calling is not a best practice for a consumer driven business. BCBSMA does tend to be a leader in health coverage - I'm surprised they utilized this tactic.

Shaun Dakin

Robocalls essentially are phone spam. The costs have decreased to the point that they are essentially equal to email and Politicians and orgs are now using them so much that there will be a backlash.

More on my call for a Voter Privacy Bill of Rights in my op-ed in the Washington Post.


Shaun Dakin
The National Political Do Not Contact Registry

B.L. Ochman

I have Empire Blue Cross thru the Freelancer's Union and I get robo-calls about my prescriptions. They tell you that your prescription is delayed and don't give you any way to reach a human. It's maddening. Healthcare is inhuman and inhuman enough already.

Ann Handley

This happens to be one of my favorite topics, Josh -- and I love that you queried BCBS about it.

Talk of health care reform usually centers on access. But we should also be talking about how to reinsert a bit more humanity—some real caring—in healthcare.

Kelley Mitchell

You mentioned you would be reluctant to give out health information to someone who called you, but wouldn't the same hold true for someone who emails you? I'm not sure if there is a good solution, but perhaps we'll figure it out through your series of how to be human. Looking forward to more posts!

Larry korte

My wife was called similarly in Virginia by Anthem BCBS. It scared her really badly and I had to talk her down when I arrived home. Insurance is very scary when you have a personal policy. Did they drop us, why do they want to know, what happened, is something wrong? It was a robo call and just said to call about a series of screening tests. Do insurance companies realize how scary the health care system is at this time?

Rachel Levy

I agree with you 100%. Any call I get from a company asking for my information seems "phishy"! I do love the automated ones from my doctor or pharmacy though.

ray manna

I don't understand why it's so hard for some service organizations to think about the needs, wants, desires of an individual BEFORE THEY THINK ABOUT WHAT'S BENEFICIAL TO THEIR ORGANIZATION.
Unfortunately, for large organizations with heavy volumes of customers composed of distinct segments, well, that's when the grace and poetry of good customer service and interaction get thrown to the curb. Maybe it's time to pony up more funding for finding better ways and systems for treating customers like people who deserve respect.

Jeremy Hilton

Customers should be treated like humans in any customer service situation in every industry.

The fact that you weren't by a health insurance organization doesn't surprise me. It's a dirty industry who's business model relies on ignoring human needs.

At one mental health insurance company that will remain unnamed, the internal term for payouts is "waste". And reduction of "waste" is what's on their mind, not helping people feel like people.

Chicago Bulls

What is amazing to me is when you call a company (any company really) and get the automated voice that requires you to enter an account number (which nobody knows or has handy) or some such other identifier. And after navigating through the maze and FINALLY reaching a human guess what the first thing is they ask for? It happens without fail.


Just wanted to share my experience of trying to complete Blue Cross's Coordination of Benefits form online. A bit confusing even without the robocall.


I agree 100% with your post. What about all the 3rd parties BCBS employs to contact you to save THEM money? Then they have the audacity to claim that they comply with hippa rules!

mickey mouse

bcbs of mass uses eliza corp. of beverly, ma to perform their health care robocalls, which were almost banned in august 2008 by congressional act, but were given an exception due to HIPAA guidelines. They remain annoying and as the original poster suggests, they have no merit or value to the call recipient or health plan member, only the insurance companies themselves. no health care benefit is provided or obtained.

Anthem's health care robocalls are handled by silverlink communications, burlington, ma.

these health care robocalls should be banned. hopefully, the new obama administration will take a fresh look at the purported value of this telephonic spam and ban these health care robocalls at the earliest opportunity.


Investors should be aware that these PBM consolidation moves will have vast deleterious effects to the revenue streams of health care CPO (Communications Process Outsourcing) vendors to the Health Care Insurers and PBMs.

The entire Health Care Insurance CPO market opportunity in 2008 was well less than $50MM. This was before the Health Care Insurance Recession of 2009.

PBMs use Health Care Communications Process Outsourcing to place those annoying "robocalls" you get at your house during dinner. Sure, the automated call is from your health plan, but the call is still you talking to a robot, and typically no "opt out" recourse to "talk to a human being" is provided.

I hear what you're thinking, reader: "Well, I thought there was a Federal 'Do Not Call' Registry to stop Robocalls and other automated call marketing spam from disturbing me at dinner, etc." Well, the Federal Trade Commission all but banned robocalls of all kinds in August of 2008, but at the insistence of PBMs and health care insurer lobbyists, created a codicil to the Telemarketing Sales Rule that allows PBMs to keep bothering you with health care communication robocalls, using HIPAA as the loophole excuse.

A Pharmacy Benefit Manager, or PBM, will use these health care robocalls in order to inform you of your prescription needing to be refilled. The average US citizen would be astounded to know how lackadaisical the PBMs are about how the drug names are pronounced, and how the dosages of the pills in your prescription are stated (or not stated) during the automated call.

TTS, or Text-To-Speech engines, basically those annoying, stilted, impersonal and mechanical "computer voices" are tasked, amazingly, with the job of pronouncing the drug names in each PBM's "formulary", or list of drugs they have in inventory. These TTS engines, as you can imagine, do a really terrible job of both pronouncing not only your name as a health plan member but also murder the names (already many are barely pronounceable by a trained human pharmacist) of the drugs in your prescription. Dosages and drug strength information is also incorrectly identified in these "automated calls", if at all.

How to tell if you've really agreed to the health care robocall filling your prescription with the wrong drug, the incorrect pill or tablet, the wrong dosage, the incorrect delivery vector? (i.e., "I take my asthma medication using a disposable inhaler; Why did my health plan send me tablets this time? This is not what I ordered! Why can't I talk to a human being? I'm paying for these robocalls!")

Imagine getting your prescription for Oxycontin 80 milligrams "refilled" by your helpful automated call program and discovering you have actually been sent in the mail Oxycontin 160 milligram tablets; If the paramedics or the county coroner aren't the ones who discover this for you.

How the legal industry has not stepped in with class-actions regarding PBMs and these robocall health care CPO vendors on the above detailed basis alone is probably just a matter of time. These health care CPO vendors are class action law suit magnets for the PBM organizations that outsource this core competency in the basis of squeezing every last dollar out of their elderly, infirm, and frequently bedridden member populations.

Look for the new Obama Administration to curtail this health care robocall activity from PBMs, particularly in a consolidating PBM industry, which is a fait accompli to become much more highly regulated by the federal government, which is a great idea. The health care of the American people deserves to be looked at through multiple public policy lenses, and not the lens of profits to PBMs and their CPO vendors.


The senior management teams of these health care CPO startups and small business enterprises never anticipated these types of government moves (i.e., reducing the government payouts to Private Health Care Insurers for Medicare Advantage, a program that the Obama Administration was publicly called a "waste of taxpayer dollars".) and had been under the impression they were operating in a "recession proof industry", whatever that was supposed to mean. In essence, nobody in the Health Insurance CPO market ever thought this could happen to their industry, and they didn't plan for this eventuality.

Communications Process Outsourcing, in the Private Health Care Insurance context, is providing robocalls (the Health Care Insurance CPO vendors' euphemistic term is "automated telephony") and direct mail (post cards and snail mail letters) to the Health Care Insurers' Member populations. These CPO vendors obtain your private medical histories and information, member data from your private health care plan and then they use hosted ISP services (yes, H1B visa-type workers, non US citizens, can do a 1-second SQL query and find out if you have cancer) to blast out the robocall to your house. These are the guys and gals who interrupt your dinner with your family after a hard day at work to ask you if you have any other insurance coverage so they don't have to pay for your medical bills, emergency health procedure, etc. Your health plan would of course like to send the bills to your spouse's insurance plan, government Medicare, Medicaid, or basically anyone else so they don't have to pay. What is the benefit to the insured member, worker, employee, person that pays the bills, the premiums, the co-pays? Well, no benefit to the "member" at all, of course. The Health Insurance CPO industry term for this supreme annoyance is "Coordination of Benefits", or Medicare COB.

Investors should be wary of the business plans of Health Care Insurance CPO providers. Business models that purport to generate huge profits and future revenue streams off of interactions with individuals of the manner described above are probably in line to get "disintermediated".

People don't interact with computers or robocall voices that bring them no benefit, economic or otherwise. Add in the fact that people find health care robocalls intensely dislikeable and annoying, even from their own health plan, and you have a receipe for a business model that doesn't scale with profitability.

Lots of investors remember the old saw about the pig farmer who lost money on every pig he sold, but he "made up for it with volume". Investors are seeing this same thought process take hold in the Health Care Insurance CPO market.

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