Industry Voices—Top 5 challenges for health plan contact centers

The stakes for delivering great customer experiences are high for health insurers. COVID-19 accelerated an era of healthcare consumerism where it is imperative for providers and plans to deliver digital experiences of care through consumer-friendly channels. As a result, member expectations have become higher for a healthcare experience that is synchronized, personalized and convenient. Today’s health plan members demand a superior customer experience, and they will increasingly shop for experiences that meet their expectations.

New regulatory requirements that directly impact payer reimbursement are also placing more emphasis on customer experience. Last year, the Centers for Medicare & Medicaid Services (CMS) changed the methodology for calculating Medicare Advantage (MA) quality scores to place greater importance on customer experience-related metrics.

With the change, patient experience, complaints and access measures will combine for 57% of overall Medicare Star ratings in 2023, up from 43% this year and 37% in 2021. Consumers use the Star ratings to select a health plan, choices that collectively impact a plan’s membership growth and retention. In addition, crucial Quality Bonus Payments are based on these ratings.

Health plan contact centers serve as the hub of member interaction and can significantly impact a member’s experience with a payer. However, many health plans have been reluctant to change from traditional reactive service strategies because they have historically viewed these communications channels as cost centers, rather than what they have become: the hub for member experience. Leading plans are already looking to contact centers to drive differentiation and strategic value, while others are just now assessing the gaps in their member journeys and searching for solutions.

Members are frustrated with plans’ customer service

A recent survey of health plan members shows that 78% of respondents say recent experiences with their insurers were “less than seamless,” while 28% reported that interactions with health plans were “very frustrating.” One might assume operations bottlenecks are the biggest reasons for member frustration, but poor customer service is the most glaring sore point—cited by 31% of respondents, versus 16% for claims denials and 13% for billing issues.

Here are the top priorities for health plan contact centers as they seek to meet member expectations for service and deliver key outcomes for payers.

1. Empower knowledgeable agents

The top challenge at the core is staffing. Agents are experiencing burnout at record levels, and the “Great Resignation” has seriously impacted payers. While an issue across all industries, it hurts payers acutely because their staff requires training, empathy and knowledge to handle the relatively complex and personal issues of plan members. And research shows that a knowledgeable agent team is a powerful positive force for member experience.

Among survey respondents who reported having positive experiences with a payer, 84% specifically credited knowledgeable agents as a key factor. The data suggest the single most impactful thing a plan can do for member experience is to ensure members connect with efficient, accurate and helpful staff members.   

A large part of that value is contextual: Health insurer agents typically interact with members frustrated about a problem or stressed about a decision they must make (such as choosing a plan or specialist). What do plan members desire most from these moments that matter?

According to research from Cigna, members want support agents to: 

  • Help them reduce plan costs 
  • Ensure they have coverage 
  • Make it easy to order and receive medication 
  • Be responsive to their needs when they have an issue 

These priorities clearly indicate that health plan members value insights and results. They want their questions answered and problems solved. But members also want their health plans to understand and relate to them as people. They don’t want to feel as if they are just another trouble ticket to a disinterested agent. Agents can’t be expected to research every member they speak with before answering the phone. They need crucial context and information at their fingertips for each interaction. For example: An agent knowing where a member is calling from, her age, and any significant health issues is rare, according to the aforementioned research. But payers have all that information, and members know they do. The challenge is synchronizing data across platforms and channels, which has been solved by cloud-native technologies. So, there is no excuse for the friction and frustration caused when members must re-explain themselves with every interaction.

2. Provide omnichannel options

Contacting a health plan for support has historically been a phone-based activity. More than one-half (52%) of respondents to the survey interact with their plans through calls to a live support agent. Yet there is growing demand among members for omnichannel support choices, including messaging, chat and email. Most legacy contact centers lack omnichannel communications and agent escalation from self-service, which hampers the ability of support staff to both help members and connect with them on a human and personal level. Health payers must focus on adding omnichannel communications, giving members control over how and when they interact with their plans.

3. Leverage artificial intelligence

A modern contact center should also leverage technology that empowers agents to deliver more personalized experiences and provide members with the right information at the right time. Agents can use AI to personalize their interactions while providing knowledgeable service to members. Intent detection can discern between positive and negative interactions from members’ verbal responses and make recommendations based on the conversation. Repetitive tasks like verifying members’ identities or outreach about preventive screenings can be automated, freeing resources for agents to have more empathetic interactions.

For payer contact centers, automation and AI aren’t merely tools to reduce costs and force more members to self-serve. They should be used to improve and extend the human-to-human interactions that are often necessary and/or preferred by members.

4. Simplify the user interface

Health plan contact centers need to be easy to navigate for faster resolution times and a better overall member experience. Routing should bring the member to the right agent at the right moment. Journey design should make it easy for customers to engage where and when they want. That means offering to route a member who had requested a prior authorization to the right team before asking him to explain the reason he is calling or forcing him to listen to a full phone tree. Or seamlessly escalating a member who engages with a chatbot (but ultimately needs live support) to an agent with full context on what the bot was and, wasn’t, able to help with.

5. Look to the cloud

A modern health plan contact center should be built on a cloud-native platform that eliminates data silos and can scale quickly. As we saw during the pandemic, scalability is vital to reliably providing a quality member experience. Payers rely on more data and tools than ever, from population health analytics to care management to marketing automation. Leveraging an architecture that makes it easier for information to flow between them all is vital. A cloud-based platform also enables faster implementation times while consuming fewer IT resources.

Health payers that continue to do business in a traditional manner face a grim future in a market where technology is driving innovation, and a consumerlike mentality is increasingly influencing member buying behaviors. Health plans need to change the way they interact with members to ensure they provide optimal customer experiences. Investing in modern, cloud-based contact centers can provide payers with a scalable and agile platform that improves agent performance, boosts member satisfaction and enables value-based care. 

Patty Hayward is the vice president of industry strategy for healthcare and life sciences at Talkdesk.