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Three areas health plans can improve the member experience


An estimated 16 million more Americans have health insurance under the Affordable Care Act-many for the first time. The online insurance marketplaces have given Americans more choice and control over their own healthcare than they’ve ever had before.

However, entering into this new market with purchasing power can be fraught with confusion, leading to consumer frustration associated with making decisions, navigating applications and enrollment, and understanding available benefits and services.

Health plans are scrambling to respond to this shift in the healthcare economy by finding ways to engage this population of newly insured Americans. They are finding that today's plan members have different needs and expectations than they had in the past.

Payers must meet the changing demands in customer service, and provide more education and guidance to support individual and population health management needs.

Here's a closer look at three areas health plans should focus on to improve the member experience.

1. Application and enrollment

Payers are selling more directly to individual consumers, who are driving selection of their own 

coverage. Consumers are often inexperienced in health insurance coverage and don’t have a benefits manager helping them navigate.

This presents an excellent opportunity for payers to provide personalized, two-way communication to educate consumers about healthcare plan options that meet their individualized cost and care needs, and guide them through the application and enrollment process.

Next: The second area health plans should focus on



2. Operations and claims management

As consumers become more empowered, to actively manage their own healthcare, they are looking for greater price transparency.

The rise in high-deductible plans encourages consumers to play a more integral role in selecting healthcare services, with affordability playing a larger role in decisions. 

This increased awareness and focus on pricing also means more scrutiny and reliance on statements and bills, which are getting more and more complex.

Consumers are often bombarded with multiple mailings about the same visit or episode, making it difficult to sort through it all to understand what’s in network vs. out-of-network; what’s covered and what is not; and, what is owed out-of-pocket. They are left to advocate for themselves and identify errors or discrepancies, and the task is more overwhelming given the confusion of the paperwork.  

This is an area ripe for change and improvement-from both the payers and providers of service. Providing clear information and appropriate levels of service and support to answer customers’ questions about statements and personal financial liability and to quickly address complaints and appeals is paramount to an excellent consumer experience-ensuring a stress-free and convenient process for the consumer.

Next: The third area to focus on

3. Care management and member support

As new members enroll in health plans through the online exchanges, payers typically have little or no information about their health, history, or care needs. This creates a challenge in supporting their individual health needs, as well as understanding and managing their member population as a whole. 

To fill in these gaps and create a better understanding prior to any services being rendered, payers should take an individualized approach to member engagement. They should create vehicles to engage early with members, utilizing technology as well as clinically trained customer care agents who directly engage new members to provide guidance on benefits, identify existing barriers to care, and offer assistance in scheduling appointments.

The results of these conversations, when combined with population-health focused data analytics, will help health plans identify member medical conditions and other risks factors early in the relationship.

The payer will then be armed with all the information needed to engage the member with an individualized care management plan for maintaining wellness and/or managing chronic conditions.   

Ultimately, we have to make it easy for consumers to utilize and pay for healthcare services and make their coverage work for them. For the payers, this requires engaging customers with a personalized experience and providing them with smart insights that will help them be a more active and educated participant in their own healthcare.

This targeted engagement creates a positive experience for members so they are more likely to select the same insurer during the next open enrollment cycle. This is critical to the long-term success of payers in this new healthcare economy.

Kelly Rakowski is senior vice president, Healthcare Payer Services, Xerox.

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