Increase efficiency to keep healthcare affordable.

Maxicare’s vision is to make healthcare affordable for every Filipino. However, healthcare costs are rising globally, meaning the business needed to find innovative ways to drive operational efficiency and avoid charging excessive premiums.

Dental was a natural place to look for efficiencies as dental benefits were heavily utilized and highly administrative. Before providing dental services, Maxicare’s partner clinics had to send Letter of Authorization (LOA) requests on behalf of members via SMS to a central processing team. A human agent would then manually verify coverage, leaving members and clinic staff waiting up to 20 minutes.

With 20,000 to 40,000 of these requests per month, the manual bottleneck became an error-prone process that couldn't scale with Maxicare’s growth or its ambitions for the member experience. 

Maxicare sought to automate this process and free its workforce to focus on providing higher-value services.

Unified platform for service paves the way for Maxicare to become an agentic enterprise. 

Maxicare’s deployment of agentic AI builds upon the business’ existing foundation with Salesforce. Previously, the HMO deployed Agentforce Service to orchestrate omnichannel care across voice, video, and live chat, while adopting Agentforce Marketing to manage SMS communications.

With access to Agentforce 360 for Health and Data 360, Maxicare aims to build on this momentum to better serve and engage its members. It also plans to extend its use of Agentforce to resolve more high-volume requests, eventually handling 100% of its non-voice traffic with agents. This transformation is expected to drive a massive 500% return on investment, while empowering the business to reallocate employees from tedious data entry to high-value clinical support roles.

Maxicare’s success with Agentforce shows that starting with a single, targeted agentic use case can make a significant impact. The business’ first agent uses clinical intelligence to reason through complex requests and either autonomously execute workflows or hand off to a human where required. 

Looking ahead, Maxicare plans to implement AI-driven workflows across other areas of the business and is exploring the benefits of migrating 100% of its non-voice traffic to digital agents. By building with Agentforce, the HMO can deploy new automations in days rather than months, all while protecting sensitive patient information.

Maxicare chose to manage the Agentforce implementation in-house to maintain control and agility. The IT team collaborated closely with Salesforce solutions experts, who provided coaching and high-level guidance on agentic concepts. 

The team’s agile approach enabled them to build and go live with their first agent in just four weeks from initial concept. The Maxicare team also gained the skills needed to make rapid adjustments later on, rather than being dependent on outside vendors. 

Maxicare shared that one of the key learnings from its rollout is that implementing AI doesn’t need to be a big, complex project to have a tremendous impact, as long as you identify a simple use case with a clear business goal. It also found that agentic AI requires rethinking the design approach and shifting from traditional, deterministic development to goal-oriented concepts of defining roles, reasoning, and adding guardrails. Ultimately, this mindset shift allows automations to be built in days rather than months, provided there is strong observability and monitoring in place.