Transforming the Health Plan Member Experience


The bad news: Health insurance is one of the lowest-rated industries when it comes to consumer satisfaction. And the good: New customer support platforms could give insurers a chance to boost member engagement and brand loyalty.

The disruptive events of the past 18 months have forced healthcare organizations to innovate and adapt in response to evolving market needs and consumer expectations. Today’s healthcare consumers not only want virtual care and telehealth services, but they also expect radically convenient customer support — from providers and payers — through the channels of their choice.

Greg Miller

Greg Miller

Health plan members now judge payers based on every interaction and touchpoint throughout their journeys. These members expect multichannel options for interacting with health organizations wherever, whenever, and however they choose. The pandemic merely accelerated a trend toward increasing consumer choice and empowerment that long has been apparent.

Some payers are getting the message. Nearly 1 in 3 (32%) commercial health plan members said in a new J.D. Power survey that they connected with their health plans over the past year via web, mobile app or text message, the highest percentage ever.

“While many plans are showing tremendous progress by delivering for their members during a highly volatile and stressful period, they still have a long way to go when it comes to delivering consistently strong levels of customer engagement across all segments of their member populations,”said James Beem, managing director, global healthcare intelligence at J.D. Power.

Indeed, health insurance remains one of the lowest-rated industries in terms of consumer satisfaction, the research firm writes. The good news for health plans is that both the demand for, and availability of, modern customer support platforms offer a great opportunity to boost member engagement and brand loyalty.

A platform for managing member interactions, powered by artificial intelligence (AI) and automation, enables payers to offer members a synchronized, personalized and convenient experience similar to what they get in more consumer-friendly industries such as online retail. This kind of communications and information hub can give payers a strong competitive differentiator.

Below are three ways a differentiated (and superior) member experience can drive value for payers.

1. Unifying the member journey

Healthcare consumers are getting what they want: a large variety of digital engagement tools in the form of mobile apps, online portals, chatbots and other technologies. But these tools typically are so poorly integrated (or not integrated at all) that they become confusing and disjointed to health plan members.

Given this wide range of platforms and channels used by payers to automate interactions or support member self-service, it’s no surprise that these point solutions make it difficult for members to navigate the system and get the right information when they need it. For members who need regular or frequent contact with their health plans due to ongoing episodes of care or management of chronic conditions, constant roadblocks and cul-de-sacs could drive them to another health plan.

Major payers are beginning to use cloud-native contact centers to orchestrate member journeys. These platforms serve as a command center for health plan member interactions by supporting omnichannel digital engagement. Such platforms can coordinate responses to member questions and requests through the channel preferred by the customer, including via live agent.

A streamlined platform that integrates with EHRs and CRMs and enables cross-channel support can speed time to resolution, improve the member experience, and enhance brand value.

2. Orchestrating health plan member outreach

The healthcare sector has a well-earned reputation for slow adoption of technologies. Perhaps the most obvious example would be traditional payer-member communications. These typically consist of 1) one-way outbound communication (mail or email) information regarding payments or benefits changes, and 2) inbound requests from members to answer questions or raise concerns. Patient queries may come through phone calls, emails, texts, patient portals, or mobile apps.

Just as cloud-native contact center platforms can unify the member journey, they can also transform the ability of payers to proactively engage members in dialogue by leveraging the same digital channels members use and prefer.

Using these digital channels to bombard members with the equivalent of spam, however, would be ill-advised and self-defeating. Rather, payers must tailor content to each member. This can be done through event-based management software that can segment member populations based on highly specific data points such as age, health status, location and channel preference.

It’s also critical that payers fully utilize the functionality of interactive digital channels such as chat and SMS, which enable them to have real-time conversations and support sessions with members. For payers in healthcare that use chatbots, natural language processing (NLP) capabilities are essential to accurately capturing medical terms and avoiding friction.

Finally, automated interactions must be seamlessly supported by (and transitioned to) human staff when necessary. There simply are limits to the types of questions and problems that can easily be handled by bots. For those interactions that require escalation or human intervention, smart routing functionality can ease member frustration and empower live agents to provide better support.

3. Driving higher quality ratings

While member acquisition and retention will remain tangible measures of success, payers increasingly are using member satisfaction in and of itself as a viable performance metric – just in time for the changes by the Centers for Medicare and Medicaid Services (CMS) that will give more weight to customer experience metrics in determining the CMS Star rating for payers’ Medicare Advantage (MA) plans.

“We estimate customer experience measures will increase from around 32% of the total weight for 2020 ratings to around 57% of the weight for 2023 ratings,” writes McKinsey. “Excellent customer experiences will be even more critical moving forward.”

Achieving and maintaining high Star Ratings is imperative to the success of MA plans, which McKinsey calls “the fastest-growing line of business for many health plans.” A platform for managing interactions can be the key to the ability of health plans to maximize MA performance payments.

Member attitudes and preferences regarding how they engage with their health plans are forcing payers to evolve or run the risk of losing business. The right technology can drive payer engagement with members and ensure a smooth customer journey.

Greg Miller is the vice president of industry strategy, healthcare and life sciences for Talkdesk.

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