Julie Billman

Top Three Areas to Evaluate in Medicare Advantage Customer Service

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A few years ago I lived in Utah, which is an amazingly beautiful state. I visited Bryce Canyon and went horseback riding into the canyon. My horse’s name was Anaconda, and his size lived up to his name. I grew up around horses, but it had been decades since I was on one. The tour started, and it wasn’t very long before I thought I made a big mistake. I had a hard time staying centered on Anaconda, and the other horses were walking right on the edge of the cliff. To top it off, I’m afraid of heights.

What saved the day was my experienced and very observant guide. He realized shortly after we got started that my stirrups were too long. He stopped and adjusted them, and that made all the difference. We were still on the edge of a drop-off, but I now felt safe. I knew my guide had things under control.

In Medicare Advantage, many of our members are walking on the edge of challenging, and sometimes scary, circumstances in their lives. Often when they need care, they need assistance to navigate the system. When events with their coverage don’t go as expected, they need guidance on next steps. Our Customer Service teams are often in a position to identify when the stirrups need adjusting.

How do we support our Customer Service teams in providing high-quality member care? Here are three areas to evaluate today.

Infrastructure to Make Change Happen for All Impacted Members. In Customer Service, we often focus on first call resolution. It is a valid focus as our members should not have to call the health plan multiple times to get their issues addressed. Once the issue is corrected, the call is logged and hopefully tracked, but what mechanism is in place to ensure any other members impacted by the same type of issue also have resolution?  Do they each need to individually call so their matter can be addressed? Customer service staff member who has to listen to the same issues over and over again with no hope of change can become easily jaded. If you want to improve member satisfaction and increase morale within your customer service area, you will set up processes to facilitate change on known issues and improve outcomes for all impacted members before they need to call the plan.

Knowledge and Ability to Triage Complaints. Complaint categorization on paper seems easy, but when you are on a call with a member relaying his or her concerns, it can be far more difficult than expected. A complaint on accessing a provider can be an organization determination, a redetermination, or a grievance. The Centers for Medicare & Medicaid Services (CMS) has formalized Call Log Universes as part of the CMS Audit Protocols because plans consistently miss categorizing complaints into the correct category, and members are negatively impacted. Providing the right education and tools to allow Customer Service staff to correctly categorize the complaint and triage it to the correct area is the only way to guarantee successful complaint management.

Customer Service Staff Who Know Where to Get Help. Customer Service is responsible for guiding and supporting members through very difficult times. Catastrophic health diagnosis, loss of loved ones, concerns about the quality of the care they received – all of these types of calls come in on a daily basis. Does your Customer Service staff know how to set up case or disease management referrals? Do they know how to recognize and report quality of care issues? Do they know it is okay to take a few extra minutes to talk to a distraught member and, where appropriate, refer them for mental healthcare? Oftentimes, the initial call concern is addressed, but the bigger overarching issue is not addressed. The bigger issue is left unresolved, not because the Customer Service representative doesn’t care, but because they don’t know how to manage the issue. Do you have an escalation path? Do you have a resource list or directory on available help to members? If not, now is the time to set them up.


Customer Service is bigger than a department or the staff answering the calls. We need to look beyond first call resolution and resolving only the individual call. We all have a part to play to ensure the stirrups are adjusted and our members are safe. It’s scary walking on the edge of a cliff, but our members aren’t there alone. We can help guide them and make the path easier to walk.

At Gorman Health Group, we know how difficult it is to provide excellent customer service on a proactive basis. We are available to join with you to ensure that vision is firmly established in your organization. We are here to help. Please contact me at jbillman@gormanhealthgroup.com if my team and I can support you and your health plan in building up your Operations team.



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Julie Billman

About Julie Billman

Julie Billman is Vice President of Operational Performance 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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