Surgery Partners autonomous voice and live exception handoff¶
Status: Draft | Last reviewed: 2026-10-06
Use this script to demonstrate an AI Voice Agent completing routine patient access work, then transferring a consequential exception to a human who uses a live Copilot. The AI verifies coverage, explains benefits, compares suitable care options, negotiates dates, handles standard affordability options, and completes permitted registration steps. The handoff concerns an existing paid booking and a financial exception needed to change hospitals.
This is an extended alternative for the access and affordability variation. Use the five-minute recording script for the current video and its simpler counselor-callback outcome. No agents, calls, records, bookings, refunds, payment agreements, or deployments were created.
Autonomy and escalation¶
Routine questions stay with the AI: why a deductible is met but coinsurance remains, why an estimate changed, whether a cheaper hospital changes patient responsibility, which billers a plan covers, and whether a standard payment arrangement fits the patient's stated budget. If authoritative evidence resolves a discrepancy within the agent's granted authority, the AI corrects the record and continues.
A material unresolved conflict or consequential action outside that authority can require a human. An explicit request for a person is also honored. Do not write the rehearsal so the patient asks for a person at the first insurance question when the objective is to demonstrate autonomy.
| Situation | AI behavior |
|---|---|
| Benefit question or routine estimate correction | Retrieve evidence, explain, recalculate with the estimate service, save the permitted correction |
| In-network alternatives and dates | Compare clinically appropriate options, check resources and approval scope, record preference |
| Standard financial assistance screening or payment offer | Use configured policy, collect required facts, present eligible options and terms |
| All requirements satisfied | Confirm booking, complete eligible forms, deliver preparation, and close without a handoff |
| Existing money paid to another billing entity, disputed refund, and nonstandard deposit terms | Gather evidence and prepare a concrete proposal; obtain the required human review before restricted commitments |
| Missing or conflicting coverage, clinical suitability, or authorization | Attempt supported resolution; preserve an accurate pending state and escalate when judgment or authority is required |
The demo boundary is a configured grant of authority, not a claim that AI cannot understand the arithmetic. A change between hospitals does not inherently require a human; this exception combines money controlled by another biller, requested nonstandard terms, and cancellation of an existing booking.
Fictional scenario¶
All patient, facility, payer, policy, financial, and timing details below are synthetic. The deposit-deferral program and billing relationships must be confirmed against real facility rules before implementation.
Elena Brooks has a right knee replacement arranged with Dr. Maya Chen at Riverside Hospital. She wants to explore a lower-cost option with the same surgeon. The care team has already established Lakeview's clinical suitability and completed its authorization work before this call. The AI verifies those records; it does not obtain a fictional instantaneous payer decision.
| Record | Demo value |
|---|---|
| Current appointment | Riverside, November 12, 2026; confirmed on the source calendar |
| Candidate appointment | Lakeview, November 19, 2026; same surgeon, suitable pathway, available resources |
| Coverage | Exact current plan and relevant provider/site network checks verified |
| Authorization | Current recorded approval covers the Lakeview procedure, side, surgeon/site, and proposed date |
| Riverside estimate | $3,600 for the listed hospital, surgeon, and anesthesia services |
| Lakeview estimate | $1,800 for the same service scope |
| Benefits used | $500 deductible remaining, 20% coinsurance, $5,000 out-of-pocket limit remaining |
| Allowed totals | Riverside $16,000; Lakeview $7,000 |
| Existing payment | $900 held by Riverside's billing entity; verified receipt/ledger entry, refund not approved or paid |
| Financial structure | Riverside's payment cannot be applied to Lakeview without an explicit authorized arrangement; no such arrangement exists in this fixture |
| Standard Lakeview offer | $200 initially and ten monthly payments of $160; fictional coordinated program for the listed billers |
| Patient constraint | Monthly amount is manageable; cannot make the new initial payment while the Riverside funds remain unavailable |
| Human exception policy | Authorized specialist may approve a documented 30-day initial-payment deferral under the seeded facility policy |
| Pre-op visit | October 29; 21 days before Lakeview and 14 days before Riverside, subject to order/facility validation |
These dates are future demonstration events relative to the October 6, 2026 research date. Use America/New_York for both facilities.
A calendar reservation does not prove current authorization for that location. If a prior authorization was amended, read its actual effect; do not assume both hospital approvals remain active. The main fixture has verified approval for the selected Lakeview option.
Act one: the AI does the patient access work¶
Plan approximately six to eight minutes of AI-led conversation. Identify the existing booking and payment during intake; do not hide known facts to manufacture a late surprise. Explain that the change may require financial review, then continue useful authorized work until there is a concrete proposal for review.
Authenticate and connect the patient screen¶
AI: “I can help compare your surgery options, check your insurance, and go through the costs. Before discussing your information, let's complete secure verification.”
Use the existing trusted authentication flow and multimodal handoff. Show a patient-facing progress indicator: Coverage → Options → Dates → Registration → Financial review → Your plan.
The AI checks current insurance details, existing appointment and payments, surgeon preference, travel and timing constraints, and support needs. The $900 payment is recorded with its actual source and status.
Resolve ordinary insurance questions¶
Elena: “Insurance approved the surgery. Why would I still owe anything?”
AI: “The approval addresses the requested procedure. Your share still follows your plan's benefits. I can show the deductible, coinsurance, and the services included in each estimate.”
The component reads verified benefit fields, source dates, and line items. If Elena supplies a newer EOB, the AI can check the document, retrieve current benefits, and recalculate through the authorized estimate service. A routine correction does not automatically trigger a handoff.
If refreshed benefits change the figures below, the conversation uses the new results. The fixture is not permission to repeat $3,600 or $1,800 when the records say otherwise.
Compare appropriate options and negotiate dates¶
AI: “Lakeview offers a clinically approved option with Dr. Chen. The listed providers check as in network, and the recorded authorization covers the proposed procedure there. The current estimate for the listed services is $1,800, compared with $3,600 at Riverside.”
Show the same scope, known exclusions, surgeon, site, authorization details, available dates, and cost calculation for each option. Do not call a lower allowed charge a patient saving unless the benefit calculation supports it.
Elena: “Can I have it on a Thursday?”
AI: “November 19 is available. Would that work?”
Elena: “Yes.”
AI: “I can place the permitted temporary hold while the financial change is reviewed. Your existing appointment will stay on the calendar until the replacement is confirmed and you authorize its cancellation.”
Hold the actual slot under the hospital's rules and show expiry. Preserve the original appointment according to its policy; do not promise an indefinite hold or medical eligibility at the old site.
Complete the permitted preparation for booking¶
The AI updates pre-registration, collects emergency-contact and support details, completes eligible administrative acknowledgments/e-signatures, and prepares the correct facility documents. It schedules or validates the ordered pre-op visit when permitted under the provisional-booking rules.
Procedure/site-dependent consent steps remain correctly labeled until their prerequisites are met. The AI can explain the next preparation steps; final site-specific instructions follow confirmed booking and clinical approval.
AI: “Your registration details are complete. The October 29 pre-op visit falls three weeks before this date; its order and location checks are recorded here. I've also saved your transport and home-help preferences.”
Say “booked,” “signed,” or “confirmed” only after the corresponding authoritative receipt. An assessment of preferences is not a support-service reservation.
Present standard affordability options and isolate the exception¶
AI: “The available standard arrangement for the listed bills is $200 initially and ten monthly payments of $160. The full terms and covered billers are on your screen.”
Elena: “The monthly amount works. But I already paid Riverside $900. I can't make another payment until that comes back. Can you move that money here and cancel the old booking?”
AI: “The $900 is recorded with Riverside, and there's no confirmed refund or arrangement to apply it here. I've prepared the Lakeview option, checked its coverage and authorization, and held the available date. A financial specialist can review a deferral of the new initial payment and the refund process before we finalize the change. May I connect you?”
Elena: “Yes.”
This is the escalation: requested financial commitments and cancellation depend on an unresolved payment held by another entity and terms outside the AI's standard offer. The AI has gathered the receipt, policy references, estimate, hold, and patient preferences before handing over. It has not canceled the old appointment, credited the $900, promised a refund, or approved an exception.
Act two: the human resolves the exception with live Copilot support¶
Plan approximately four to five minutes. The human takes over the same call and patient screen. The AI stops speaking after a successful transfer; automation can execute reviewed actions in the background.
Start with completed work and one decision¶
Copilot handoff card: “Verified patient. Lakeview selected with Dr. Chen, November 19. $1,800 estimate; network and selected-site authorization verified; temporary slot hold expires at the recorded time. Registration completed as permitted; pre-op requirements checked. Riverside appointment remains on calendar. $900 payment verified there, refund unapproved. Standard monthly terms acceptable; patient needs initial-payment deferral. No cancellation, credit, or charge performed.”
Jordan, financial specialist: “Elena, I have the Lakeview plan and the Riverside payment details. The remaining issue is how to handle the new initial payment while that refund is unresolved, and then complete the booking change in the right order.”
Reconcile money and explain the patient's options¶
Elena: “So do I owe $1,800, or $900 after what I've already paid?”
Copilot: Opens a side-by-side payment and estimate view: Lakeview estimate $1,800; Riverside payment $900; no verified cross-account credit or refund. Links the source ledgers and policies.
Jordan: “The Lakeview estimate is $1,800. The $900 you paid is still recorded with Riverside; it hasn't reduced Lakeview's balance. I'll help with the refund request and review whether we can defer the new initial payment.”
The Copilot must not present the same money as both refunded to the patient and credited to the new account. A refundable balance, refund request, approved refund, and settled refund are separate states.
Review a meaningful financial exception¶
Elena: “I can manage the monthly amount, but I need time to get that money back.”
Copilot: Shows the actual facility exception policy, conditions, required evidence, representative authority, proposed due date, interest/fees, included billers, and reviewable terms. The main fixture supports a 30-day deferral of the $200 initial payment; the remaining ten $160 payments still total an estimated $1,800 with that initial payment.
Jordan, after policy review: “Under this program, I can approve a 30-day deferral of the $200 initial payment. That gives you time without treating the Riverside money as already transferred. Here are the exact dates and terms for review.”
Elena: “What if the refund still hasn't arrived by then?”
Copilot: Surfaces refund status, the earlier follow-up deadline, the responsible team, and the policy's next review path. It does not invent a refund date or a further automatic extension.
Jordan: “I'll set a follow-up before that payment is due. If the refund is still pending, the financial team will review the next step with you. I can't promise Riverside's refund timing.”
Record the reviewed exception, its basis, authority, exact financial schedule, and patient's agreement. Do not silently activate a charge or a credit product.
Complete the booking change without losing track of the original¶
Elena: “Will I lose my current date before the new one is confirmed? Does the insurance approval work at Lakeview?”
Copilot: Displays selected-site authorization scope, clinical prerequisites, original booking, live replacement hold, and cancellation/refund conditions. Suggests the next action allowed by the actual status.
Jordan: “The recorded approval covers the Lakeview details we're using. I'll confirm the replacement first, then cancel the original appointment with your agreement. The refund request will have its own confirmation and status.”
After explicit patient agreement, use the booking system's supported replacement transaction or a reviewed sequence with recovery steps. Do not fabricate an atomic transaction across independent systems. Confirm the new booking receipt before requesting cancellation of the original; read back the cancellation outcome. A failed cancellation remains an owned open task and is disclosed.
A financial specialist cannot approve a payer request or decide a new care setting's clinical suitability. In a branch with missing selected-site authorization or clinical clearance, retain a provisional plan and assigned follow-up. Do not claim the surgery is fully confirmed merely because the payment exception was approved.
Finish with preparation and an accurate summary¶
Jordan, after the booking receipts: “Lakeview is confirmed for November 19. The original appointment's status, the Riverside refund request, and the deferred-payment terms are shown separately in your plan. Let's finish the remaining forms and preparation checklist.”
Reuse the AI's completed intake, permitted signatures, and pre-op/support work. Finish only the remaining steps. Read approved clinical instructions; route medication or clinical consent questions to the appropriate clinician. The financial specialist does not prescribe a new regimen.
The Copilot drafts a wrap-up from actual receipts. Jordan reviews and saves it. If authorization or another external prerequisite remains pending in a different fixture, the AI can later make the confirmation/preparation call when the required evidence arrives.
Make both capabilities visible¶
| During AI conversation | During human conversation |
|---|---|
| Trusted authentication and secure patient screen | Handoff brief containing completed work and the exact unresolved decision |
| Insurance-card/EOB intake and benefit reconciliation | Existing-payment ledger versus new-provider estimate |
| Verified network, clinical option, and authorization checks | Refund evidence, policy, and confirmed versus pending outcomes |
| Dynamic cost comparison and date negotiation | Authority-backed deposit-deferral proposal |
| Standard assistance/payment options and biller scope | Live answers about total obligation, refund timing, and dates |
| Permitted forms, pre-op scheduling, support arrangements | Reviewed booking change, cancellation sequence, and remaining preparation |
| Saved proposal and precisely scoped escalation | Reviewed exception receipt, written patient plan, and wrap-up |
The Copilot changes with the live utterances and trusted record updates. The representative's actions update Salesforce and the same patient-facing components. Internal policy reasoning remains private; patient-relevant decisions, terms, and statuses appear on the patient screen.
Salesforce and execution contract¶
Extend the original build contract with:
- Current and candidate bookings, resource holds, expiry, clinical readiness, and site-specific authorization references.
- Versioned benefits, estimates, network evidence, and patient preferences, all gathered by the AI where authorized.
- A payment ledger keyed by billing entity, patient, episode, and receipt; separate verified, requested, approved, settled, credited, and disputed states.
- Configured AI and human transaction permissions, standard offers, exception policies, and required approver roles.
- An exception request holding the concrete AI-prepared proposal and supporting evidence.
- A reviewed financial agreement with exact terms, scope, patient acceptance, and charge status.
- Booking/cancellation/refund request receipts with retry, reconciliation, and recovery handling.
Cross-biller refunds, deposit deferrals, and cancellation authority are fixture-specific policies, not universal rules. If a production agreement gives the AI a safe, deterministic way to complete a change within its grant, allow it to finish autonomously. Human review should not be added just to force a demo transfer.
Acceptance cases¶
| Case | Expected result |
|---|---|
| Ordinary benefit question | AI answers from verified records and continues |
| EOB reveals a routine outdated estimate | AI verifies and corrects within its granted authority |
| A cheaper hospital has the same patient share after applying benefits | AI explains the real comparison and follows patient preference |
| Standard booking and payment terms work | AI finishes the full journey with no handoff |
| Existing third-party payment and nonstandard deferral request | AI assembles evidence and proposal; human reviews the restricted commitments |
| Unverified receipt or refund | No credit, refund promise, or financial-state fabrication |
| Wrong site/procedure/date on authorization | No unsupported confirmed booking |
| Replacement confirmation fails | Existing appointment not canceled by the attempted switch |
| Original cancellation fails after replacement | Explicit open task and truthful patient communication |
| Exception cannot be approved | No fabricated waiver; human explains real options and records the patient's choice |
| Patient asks for a person earlier | Honor the request; do not force completion of the AI segment |
Research and status¶
The research notes and revenue-cycle sources cover benefits, estimates, consent, preparation, and financial-program scope. The previously retrieved sources below explain benefits and the relationship between an EOB, a bill, and payments; they do not establish this fictional deposit/refund policy.
https://www.healthcare.gov/glossary/deductible/
https://www.healthcare.gov/glossary/co-insurance/
https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/
https://www.healthcare.gov/glossary/preauthorization/
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/guides-resources/read-explanation-benefits
No new external policy claim is introduced by the exception fixture. Actual payer scope, cancellation conditions, billing agreements, refund rights, deferral authority, and integration support need validation before building. No application or telephony checks have been performed for this proposal.