By Sagar Shankaran, Founder of CallSphere
Why the January service spike breaks benefits agencies, how 2026 forecasting models size it group by group, and how to price a PEPM fee to real ticket load.
Key takeaways
You tried forecasting once. Somebody put a trendline on three years of ticket counts in a spreadsheet and it told you January would be busy. You already knew January would be busy. That is the objection, it is fair, and it is why most agency principals stopped looking at this after one attempt.
What changed in 2026 is not that forecasting became possible. It is that the forecast finally got specific enough to act on — not "January is heavy" but "the first nine business days will run at 2.7 times normal volume, and 61% of it will come from eleven named groups, nine of which changed carrier or network on 1 January." One of those sentences is trivia. The other one is a staffing plan and a pricing decision.
Every benefits agency prices its service by headcount — a per employee per month consulting fee, or a commission that works out to roughly the same thing. Every benefits agency is then surprised, every year, that headcount predicts almost nothing about how much service an account consumes.
A 400-life manufacturer with a stable workforce, one plan option and a bilingual HR manager who handles her own ID card questions generates maybe 500 tickets a year. A 400-life multi-state home care company with 70% annual turnover, four plan options, a new carrier and no HR department beyond one office manager generates four times that, and every one of those tickets lands on the same account manager who is also handling eleven other groups.
The number that actually drives a benefits agency's cost is service tickets per hundred covered lives per year, and almost nobody measures it at the group level. It sits in the service inbox and the phone system and nowhere else.
The January spike is not one thing, it is five things arriving in the same nine days. Deductibles reset on the first, so every claim in the first three weeks feels wrong to the member. New ID cards either arrived or did not, and the ones that did not become pharmacy counter calls on 2 January, when someone is standing at the register being told their prescription is $340. Networks changed on the groups that moved carriers, so the specialist someone has seen for six years is now out of network and nobody read the letter in November.
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Then there is the quiet one. The enrollment file sent to the carrier in mid-December — the EDI 834 — came back with errors on a handful of members: a dependent date of birth mismatch, a Social Security number transposed, a mid-December new hire whose effective date landed wrong. Nobody worked the error report over the holidays. Those people find out they are "not eligible" at a doctor's office on 6 January, and each one is a forty-minute call plus a follow-up plus an apology to the HR director.
Layer on COBRA notices for December terminations, Section 125 election questions from people who forgot what they picked, and the first payroll of the year showing a deduction that does not match what the employee remembers electing. That is the shape of the week, and it repeats with the precision of a tide.
flowchart TD
A["Last three Januaries of ticket history"] --> E["Forecast: calls per week, per group"]
B["Groups that changed carrier or network on 1/1"] --> E
C["December 834 error counts per group"] --> E
D["Headcount, turnover and dependent mix"] --> E
E --> F["Staffing plan for the first nine business days"]
E --> G["PEPM fee band for next year's quote"]
A benefits agency's history is the worst possible input for classical forecasting. Each group has one renewal a year, so you have three or four observations per group, not three hundred. Two-thirds of them land on the same date, so the seasonality is one enormous spike and eleven quiet months. Groups leave, join, get acquired, change carriers, split into two tax IDs. Half the useful signal is not a number at all — it is "this group moved from a national carrier to a regional one with a narrower hospital network."
That is exactly the mess that put demand forecasting at roughly 48% adoption in manufacturing and pricing work at around 72% in retail and e-commerce by 2026: modern models handle sparse, lumpy, seasonal history and free-text notes together, where a trendline needed a clean series it was never going to get. For an agency, the practical version is that you can hand over three years of ticket exports, the renewal log, the December error reports and the account managers' notes, and get back a per-group estimate instead of one company-wide curve.
Here is where the forecast earns real money rather than saving overtime. When a producer quotes a per employee per month consulting fee on a 400-life prospect, that number today comes from the last three deals and a gut feel. If instead the quote comes with a predicted ticket load based on the things that actually drive it — carrier change in year one, number of plan options, workforce turnover, multi-state footprint, share of the workforce that will need Spanish-language support, whether the group is moving to level-funded — the fee lands in the right band before you sign, not after.
The uncomfortable part is that this will tell you some of your existing accounts are underwater. Most agencies have two or three. Knowing which ones, with a number attached, is the beginning of either a fee conversation at renewal or a decision to let the account go to a competitor who has not done this arithmetic.
Illustrative numbers, and worth rebuilding with your own. Assume 180 groups, 11,000 covered lives, six service staff each comfortably handling 230 tickets a month, a normal month of 1,150 tickets and a January of 3,100.
| January staffing | Guessed | Forecast in October |
|---|---|---|
| Overtime hours across six staff | 132 at $52 | 48 at $52 |
| Overtime cost | $6,864 | $2,496 |
| Seasonal help | 2 temps, 6 weeks, hired in January at $28/hr | 2 temps, 6 weeks, hired in November at $24/hr |
| Seasonal cost | $10,080 | $8,640 |
| Total | $16,944 | $11,136 |
| Backlog at worst point | 9 business days | 3 business days |
The $5,808 saved is the small half. The pricing half: take one 400-life account quoted at $4.50 per employee per month, so $21,600 a year. It changed carriers, it is in five states, and it runs 1,540 tickets a year. At a fully loaded $19 per ticket that is $29,260 of service against $21,600 of fee — a $7,660 loss on an account everyone in the office thinks is a good one. Quoted at $7.00 in the right band, it bills $33,600 and works. One repriced account pays for the whole exercise, and most books have more than one.
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It will not know that the HR director at your third-largest group is leaving in November, and that her replacement will route every question she used to answer straight to your service line. It will not know about the acquisition announced in February that doubles a group's headcount overnight, or the carrier's claims system problem in week two that generates 200 calls in three days. Those are the events that actually blow up a January, and no amount of history contains them.
It also will not tell you whether to fire a client. An account that runs unprofitably on tickets may be the reference that wins you three others in the same industry, or it may be the group whose broker of record letter is worth more to a competitor than to you. That call belongs to the principal, with the forecast as one input among several.
And a forecast that nobody staffs to is theatre. If the October number says you need two temps hired in November and the answer in November is "let's see how it goes," you have spent money to be precisely informed about a problem you then walked into anyway.
Start with the phone system and the shared service inbox, both of which already have exports nobody looks at. Three years of call records with the caller's group identified gets you most of the way. If your service email is a shared mailbox with no case system, the first month's work is tagging by group, and that alone will surprise you.
Easier to forecast, harder to survive. A concentrated book means the spike is bigger but far more predictable, and the per-group drivers are the same every year. Agencies with a spread of 1 July and 1 October renewals get a smoother year but a fuzzier signal.
Have the January number by mid-October. That is late enough to know which groups actually moved carriers on renewal and early enough to hire and train seasonal help before the December enrollment crunch swallows everyone's calendar.
Probably not, and be careful about selling it internally that way. What it usually does is stop the January collapse that costs you a group or two every year, and move two or three accounts from unprofitable to profitable at renewal. Both of those show up in margin, not in headcount.
The other half of a nine-day spike is simply picking up the phone. Even a perfectly staffed January has a Monday where eleven calls land in the same four minutes and eight go to voicemail. CallSphere builds AI voice and chat agents that answer the service line and web chat around the clock, take the member, group and ID card details, book the call-back and hand a clean note to the account manager. It will not forecast anything. It just means the overflow becomes a queue you can see and staff to, instead of a voicemail box you work through on Thursday.
Written by
Sagar Shankaran· Founder, CallSphere
LinkedInSagar Shankaran is the founder of CallSphere, where he builds production AI voice and chat agents deployed across healthcare, hospitality, real estate, and home services. He writes about agentic AI, LLM engineering, and shipping voice agents that handle real calls in production.
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