Four Potential Failures of Your Member’s Experience

It’s the Annual Election Period (AEP) for Medicare Advantage (MA), and like many health plans, those of us in the industry are often busy.  I was very fortunate early in my career.  I had great mentors as well as good processes set up to reinforce that operations is not just production but is about the member.  I was part of a centralized operations organization that supported health plans throughout the country.  Once a year those health plans would score each operations team on a 1 – 10 scale with scores of 9 and 10 not just being responsive and productive, but demonstrating that your operation was a “selling advantage”.  This concept reinforced the concept that all our operations team had a part to play in providing a positive member experience from the first moment.  I shared this with my teams and we discussed what that means in practical ways that each person could implement.  My team was proud of the scores of 9 and 10 we received from each health plan. 

Oftentimes, member experience programs don’t consider the whole picture and how more hidden operations functions can impact member experience and retention. In doing so, you lose a valuable resource to improve your member’s lives.

Here are four actions that may sabotaging your member experience resulting in member abrasion at best and disenrolled members at worst:

  1. Not Creating a Communication Plan.  In order to create a successful AEP, you need a communication plan to outline how changes are communicated within and outside of the plan.  This communication plan should address several questions.  How will two way communication be managed this AEP.  How will changes and updates be communicated to staff?  How will member reported issues be escalated promptly for prompt resolution.  Who is creating the talking points and scripts needed by staff to explain new benefits or negative benefit changes?  Don’t set front line staff up to “create” their own messages.   Support them with the information up front and be prepared to modify the language as unclear messages or new concerns are raised. 
  • Failure to Follow Up Aggressively on Applications with Missing Information. The regulations require an outreach to occur when information is missing from an application. Often health plans simply send the Request for Information letter to members when more information is needed, yet the health plan just invested significant time and energy to obtain the application and often, due to staffing levels, only sends a standardized letter requesting additional information. This is often the first interaction post application – is this really the first impression a health plan wants to give its new member? This will result in negative experiences and lost members before they ever had a chance to receive an identification card.
  • Unclear EOB or Denial Message Codes. EOB and denial notices are to allow members to understand what needs to occur to potentially get the service covered or what cost-sharing liability is. Are your EOB message codes or denial reasons clear and understandable to an average member? Does it let the member know what action they need, or don’t need, to take? Does it imply more member liability than the member actually owes? A thorough review of your EOB message and denial codes to validate they are accurate and communicate clearly what the next steps are supports the best member experience possible for members’ claims.
  • Hidden Year-over-Year Changes. Complaints often spike in January and February each year. This is often due to changes from the previous year members didn’t understand. Sometimes it is because members didn’t read their Annual Notice of Change (ANOC). Many health plans have retention meetings, particularly when there are significant changes year over year, to educate members on upcoming changes. Sometimes plans make changes and don’t clearly identify those changes to the impacted members. Health plans may change their process from not disenrolling members for non-payment of premium to disenrolling members for non-payment of premium, and the only notification is an update in the several-hundred-page Evidence of Coverage (EOC). The health plan may correct an error in claims processing from previous years that results in an accurate but negative member cost sharing with no notification to impacted members. Members only find out about the change after services are rendered and they receive an EOB or bill. It is important to consider the end impact of internal changes to members. Are there ways to notify potentially impacted members to allow upfront knowledge? For a change in your delinquency process, can invoices be updated with language about disenrollment for non-payment of premium? Can you put a flyer in your premium delinquency notice about the upcoming change? The news might generate calls and concerns, but it is better to handle them proactively rather than after the member is disenrolled and they are calling Medicare to complain. Bad news is sometimes a reality, but proactive support can lessen the impact to the members.

Our members’ experiences are a combined effort of all the functions within the health plan, member facing or not. It’s time for all the functional areas to own member experience. Changes can have big impacts on maintaining a member’s trust or causing concern and potentially losing the member forever.

GHG’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 us by completing this Get in Touch electronic form or by emailing me directly at jfox@gormanhealthgroup.com.

Jeff Fox
Jeff Fox

Jeff Fox is President of Gorman Health Group (GHG). In this role as a member of GHG’s senior leadership team for more than a decade, he is intimately involved with aspects of both business development and client engagement management. Jeff brings GHG clients more than 25 years of experience as one of the nation’s leading experts on government-sponsored programs as well as a passion for health insurance sales, marketing, and product development.

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