Reflecting on 2017 to Improve Your 2018 Member Experience

When you think of the ideal strategic partner, what words come to mind to describe them? For me, those terms are honesty, integrity, value-add, vision, and an understanding of my needs.  These are the same things that members are expecting from us when they choose our health plan to provide their health insurance.  As we start 2018, all of our staff have the opportunity to prove our commitment and demonstrate our health plan’s core values to enhance our members’ experiences.  As you enter into 2018, here are some reminders of critical components to support your members in 2018.

  1. Does Each Staff Person Know Their Impact on a Member’s Experience?   On a recent project, I worked with a client that had a high volume of overturned pre-service appeals.  The root cause was an inability to get required information, within the timeframe, during the pre-service decision.  The view was that the member ultimately received the service, but more time was allowed to obtain missing information to validate if the service should be approved.  There was a serious disconnect in how these denials impacted the members.  The person responsible for overseeing the process wasn’t uncaring, but was unable to obtain provider responses timely and had no support in resolving the issue, so rationalized the end outcome.  It is unfortunate that sometimes it takes an outside consultant to assist in raising issues in the right context to facilitate change so the process could be fixed at the pre-service organization determination level.Sales and customer service are the face of your organization to members and are often the most trained on their impact to members. Member experience is far reaching but is often not as clear to back office staff.  Does the team that manages the provider directory creation sit on the complaint committee or review complaints on provider directory errors?  Does the person that reviews low-income subsidy mismatches understand the impact on a member’s prescription cost share?  Does the prior authorization or claims management know the overturn rate of upon appeal, particularly due to missing information?  Are disenrollments tracked back to the root cause for enhancements of process and functions?
  2. The Goal of Your Member Interactions Should be to Provide Understandable Guidance and Clear Explanations. We had several projects in 2017 that involved member complaints about provider access.  Either the providers in the directory were no longer valid or the provider wait times were too long.  Members contacted customer service and received little valid assistance as there were no clear instructions for this type of situation, even though it had been occurring for some time.  Often customer service just provided a listing of other potential providers the member could contact.  There were several failures in the process from incorrect provider directory data to a lack of clarity regarding when a member was requesting access to out-of-network care due to a lack of access.  Clearer guidance and providing valid next steps to the member, along with root cause analysis, resulted in improvements for the impacted member and future members.Do you know your member touch points and what is conveyed at those touch points? Has the organization created talking points for customer service that provide clear explanations on responses and escalation steps for members’ concerns?  Do staff who speak with members have access to all member communications and letters?  Is claims and pre-service denial language clear enough that both members and customer service know the next steps to support an appeal?  Are explanation of benefits notices clear enough to indicate when there is a member liability and when there is not?  Does enrollment know the importance of member retention as they reach out to gather missing information from an enrollment form?  Is customer service empowered enough to assist in problem resolution and guide members in the process of accessing health care?  Is there a feedback loop that can improve common member pain points?  Do your vendors know the importance of making the right initial decision?
  3. How is 2018 Better than 2017?  Are the same issues plaguing your health plan this year that were impacting you last year?  We often are so busy keeping things afloat that we fail to improve processes, but this is critical to success.  What did each of your teams learn in 2017 that can be done better in 2018?  Survey your staff to identify the top issues impacting members and the suggested improvements.  If you don’t already have a process, consider methods I outlined here. We see time and time again how demoralized staff feel when they know something is wrong and can’t get support to get it corrected.

2018 is a blank slate and you have an opportunity to determine what kind of partner you want to be for your members. What words do you want them to use to describe your organization?  A mentor of mine taught me early on that “People don’t wake up wanting to do a bad job at work.”  It is all of our jobs to take the time to educate, encourage, and support our staff to exemplify our health plan’s core values and be the health plan we would be proud to enroll our family members.

GHG’s experienced consultants can support you as you take a closer look at your members’ 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 members’ experience, please contact us by completing this Get in Touch electronic form or by emailing me directly at




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