Focus on the Entire Iceberg, Less on Individual Members

“What we do and accomplish is only the tip of the iceberg of what’s possible for us,” said Les Brown, motivational speaker. That quote is powerful, not just for individual personal growth, but for what we should consider in our jobs and as we work with our members. In Customer Service and Appeals & Grievances departments, we often focus on the individual member, which is obviously important but is just scratching the surface. Focus on first-call resolution, empathy to the member, and appropriate member-friendly resolution to member complaints should be the baseline at every health plan. We need to move beyond that baseline to what is under the surface.

Let’s discuss three ways plans can move towards that higher level:

  1. Look Below the Surface. Have you seen the image of an iceberg that shows both what is above the waterline and what is below the waterline? It is an amazing photo aesthetically, but what is most amazing is what is below the water’s surface. It is massive, and what you see is such a small portion of the full iceberg. Often we receive a complaint from our members and deal with the surface issue but ignore the bigger problem. A member may contact the plan unable to find a physician. The customer service representative helps the member locate a physician, but the fact the provider directory has outdated information is not addressed. We helped that individual member, but there are many other members experiencing the same issue today. The resolution has no impact on the future member’s experience.
  2. Capture the Right Information. We have all heard the phrase, “If it isn’t documented it didn’t happen.” It’s true in an audit or when someone else is trying to research the issue, but it’s more than that. If it isn’t documented in a retrievable analytical manner, it can’t be easily trended. We regularly meet with staff who are passionate about their members’ experience. They know they have data that can help improve the process, but they can’t get at it. Take some time to determine the barriers to obtaining good data systematically, and work on mitigation strategies to support data analytics.
  3. Utilize the Data. We have so much data! We have information on:
    • Who calls the most
    • Why our members call
    • When our members call
    • Which benefits are causing the most confusion
    • Which benefits members are using
    • How many of our appeals are overturned internally
    • Which providers don’t respond timely to our requests for more information

Rarely is that information used to its fullest impact. Sometimes it’s because we can’t get the information out of the system or aren’t tracking it. Sometimes it’s because we don’t have the resources or skill to trend the information. Just as radar allows a ship to identify the part of the iceberg below the surface to protect the ship and passengers, we need to trend issues to improve our program. We should be using the pain and barriers our members experienced to prevent future members from experiencing the same thing.

The titanic identified the iceberg on the surface. It sank because it underestimated what was underneath. Better technology based on that and other experiences prevents similar events today. With today’s software and analytics we should be using all methods at our disposal to ensure we are taking care of the issue the member in front of us raised as well as the members to come. Plan staff is busier now than they have ever been. The only way to get ahead of member experience and truly become more efficient and truly member centric is to utilize all the information we receive. We can continue to staff to treat only the iceberg we see, but to truly make a difference, we must address the whole iceberg.

Gorman Health Group’s experienced consultants can support you as you take a closer look at your member experiences. Our focus is quality, compliant, efficient, and member-focused health plan operations to help your plan retain members. If you would like more information about maximizing your member’s experience, please contact Gorman Health Group by clicking here or by emailing me directly at jbillman@gormanhealthgroup.com.


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Julie Billman
Julie Billman

Julie Billman is Senior Vice President of Operational Performance & Provider Strategies at Gorman Health Group (GHG). In this role, health plans look to her to improve operational functions, maximize plan revenue, and educate plan staff to understand and own the Medicare requirements that govern their functions. Read more

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