The Rewards of Service: How Medicare Insurers Can Become Star Performers


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The star rating system mandated by the Centers for Medicare and Medicaid Services’ (CMS) —and an evolving healthcare landscape in general—is bringing new challenges to the Medicare market. But those challenges are not insurmountable.

With the introduction of the star rating system, insurers are now being calibrated on a five-star scale based on a number of criteria—a key one being feedback surveys sent to Medicare beneficiaries asking them about their service experience. Much like consumer satisfaction ratings for restaurants or hotels, this rating system for insurers is designed to offer a concise, easy-to-understand scale to help consumers make informed decisions.

Not only does the publication of these ratings at mean underperforming insurers could experience lower enrollments or churn through special five-star enrollment periods, but the ratings become the basis for a CMS bonus system affecting Medicare Advantage plans – a powerful incentive considering the government has reduced the amount of Medicare payments to insurers over the past several years.

More than ever now, for you as an insurer, there is a direct link between the customer experience and your bottom line.

A major challenge to earning a 5-star rating is current beneficiary perceptions about the quality of the customer experience delivered by the Medicare plan. A recent study from Forrester Research found that the health insurance industry in general has the lowest customer experience ranking of more than a dozen industries.

According to Convergys 2011 Scorecard Research into the customer experience, Medicare beneficiaries are looking for fast answers and accurate information without a lot of excess effort and frustration on their part.

The key to influencing a 5-star experience means getting out in front of those CMS surveys with a customer-centric focus—which in turn will help drive your star ratings results. To do this, insurers should consider the following:

  • Take Ownership of Customer Issues – All contact centers live by the mantra of first-call resolution, but the complex world of Medicare health plans and its related customer issues don’t always permit a one-and-done customer experience. In these instances the focus becomes assuming responsibility for the issue and seeing it through to resolution even if it takes a few steps and calls. An effective knowledgebase is critical to providing this level of service. Ideally, the knowledgebase would integrate with an insurer’s other back office systems in order to create a comprehensive view of the customer based on beneficiary-related data such as health assessments, claims, eligibility information and so on. The knowledgebase should also be equipped with a decisioning engine that allows it to analyze customer information and history to suggest appropriate responses and personalized courses of action to help agents resolve issues in a timely manner.
  • Uncover Root Causes of Experience ProblemsAnalytics can be used to help identify processes and behaviors that contribute to customer satisfaction and frustration. This information can be used to implement best practices and improve upon customer pain points. In addition, customer feedback can be used to discover problems beyond the call center. For example, customer feedback could give you insight into doctor office visits that you could report back to improve the experience there, which can further contribute to your star rating.
  • Enable Multichannel Interactions – Phone support continues to be the most preferred method of interaction for customer service followed by self-service websites and email. Some interest does exist for newer technologies such as Web chat, social media and text messaging. As younger caregivers assume responsibility for Medicare beneficiaries, use of these new channels is likely to grow, increasing the importance of multichannel support.
  • Effectively Handling Appeals and Grievances – Medicare insurers are required to report patient complaints related to their claims and coverage to the CMS and therefore must track them accurately. Appeals and grievances are typically tracked by agents, but as some insurers have found the use of speech analytics can add accuracy to the process. The analytics system listens for key words that indicate a problem and then sends an alert to the agent reminding them to log the problem. A decisioning engine can also be used to properly classify and track grievances. This process is particularly important as under- or over-classifying can cost an insurer significantly.

Consumers today are accustomed to having instant access to customer reviews on products, devices and experiences. From books to computers to cars, before they pull out their wallets, consumers consult their laptops and smartphones to make sure they are getting the most for their money.

The CMS star rating program for insurers is a sign of the B2C shift my colleague, Christine Kowalczyk, discussed in her recent blog. As the health care market evolves and the star rating program takes on more significance to consumers, Medicare insurers will be challenged to evolve themselves.

Cory White
Cory White is the Health Care Vertical Leader for Convergys an industry leader in providing agent-assisted, self-service, and proactive care solutions that support its client customers worldwide.


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