A senior member has trouble getting a prescription filled and calls your member services line. Your representative confirms that the member’s Medicare Advantage policy doesn’t cover the requested prescription at the prescribed amount. But the representative lacks experience and doesn’t offer a solution during the call, which leads to more calls and emails from the member. By the time your specialist team gets involved and resolves the issue, several days have passed. Meanwhile, the member is without medication and growing sicker by the day. Even after the prescription is filled, the member is still unhappy — and the next survey reflects that.
Your contact centre plays an important role in both the member experience and plan management. And skilled representatives are the key to successful outcomes. Every interaction matters. Members need to know that your representatives hear and understand them. They expect fast, efficient service. And sometimes, they depend on your representatives to guide them to solutions. Even small mistakes, oversights and delays can negatively affect members’ health outcomes — and, as a result, how they feel about the plan. Taken together, too many issues like missed coverage determinations or members out of care plan adherence can cause your Star Rating to drop. It’s a quality management nightmare.
To maintain your rating and protect your bottom line, your representatives need to meet members’ needs in every interaction. That takes comprehensive training and coaching, along with access to the right tools and information at the right time. Technology solutions can help with both, empowering your contact centre staff to drive quality assurance and compliance.
Your contact centre solution can — and should — do more than enable interactions with members. It should help your representatives proactively identify and resolve members’ problems and even prevent unnecessary appeals and other undesirable outcomes, along with their associated expenses. To achieve that goal, your solution needs to include a robust set of features, integrations and workforce engagement tools.
Give representatives the context they need to solve problems proactively
Contact centre representatives move from one issue to another — one member to another — all day. When they’re intently focused on answering a member’s question or resolving a specific issue, it’s easy to lose sight of the big picture. And that means losing the context of the member’s journey.
Integrating your contact centre solution with your CRM system and other systems, such as claims and plan management, can provide your team with the information they need to see the current interaction within the broader member journey. Armed with this critical context, representatives can think more holistically and take more proactive measures. For example, with additional information from the CRM system, the representative can see that a member hasn’t had a diabetes checkup in the past year. The rep can route that member to the clinical team for review. This kind of proactive service can help improve patients’ outcomes while keeping costs down.
Use analytics for faster resolution and more cost-effective management
Maintaining performance on key metrics requires more than simply addressing members’ inquiries in a timely fashion. It requires proactive oversight, analysis and action. Real-time analytics can enhance contextual information for the representative. Every member interaction — voice and digital — is packed with information. With analytics running in real time, your contact centre solution can provide representatives with an assist on every call and chat by surfacing relevant information and suggesting next steps.
For example, a member calls to see if their policy covers a particular smoking cessation therapy. While the representative answers that specific question, the real-time analytics catches the mention of smoking cessation and pops up additional guidance on the representative’s screen. With that prompt, the representative lets the member know they’re eligible for a program with nurses who provide support throughout their journey to quit smoking. This proactive offer to the member ensures cost-effective management of the care plan.
Additional analytics, driven by word spotting and sentiment analysis, aids the representative in identifying issues after each interaction and resolving them before they escalate. After a difficult call, the representative sees that the interaction is flagged as a possible coverage determination issue based on word spotting. Plus, the sentiment analysis shows that the member had a negative experience. The representative can refer the issue for immediate follow-up, which could keep the member in adherence with the care plan and prevent an appeal. This proactive service leads to better health outcomes for the member, which creates a higher member satisfaction rate. It also prevents unnecessary expenditures for you — and keeps your ratings from declining.
Provide representatives with targeted coaching
Conversation analytics can benefit team leads, too. Dashboards can display aggregate data for every interaction, enabling leads to review their team members’ performance and identify areas for improvement. When a problem is noted, the team lead can examine the entire transcript to understand the details of the interaction. Annotation based on word or topic spotting and correlated sentiment analysis makes it easy to pinpoint trouble spots and offer targeted coaching right away.
Monitoring the entire team, the lead might discover patterns in interactions the representatives handled well or in topics where something was missed. As a result, the lead can schedule more comprehensive training and reach out to the clinical team for support and follow-up on specific interactions, if needed.
Analyse every interaction for more comprehensive quality management
With the right analytics in place, you can drive quality management by extracting insights into the member journey and plan performance. Despite the abundance of technology, quality management has often remained a manual process of listening to a random sample of calls. And that all but guarantees you’ll miss some of the calls that require additional action or intervention. If you’re not analysing all your interactions across channels, you’re missing critical insights that could improve plan management and protect your metrics.
You can eliminate these manual evaluation techniques and save time with automated workflows that drive quality at scale. With speech and text analytics in place across channels, you won’t miss a thing. The quality management team can spot trends in aggregate data and target issues for improvement across a team or service line. They can mine both calls and digital interactions for actionable insights, then combine that data with other key metrics — such as determinants of health — for a more comprehensive quality management plan.
Empower representatives to drive their own improvement
Solutions that include comprehensive tools for workforce engagement empower representatives to review, manage and improve their own performance. If your representatives are waiting on managers to run weekly performance reports, then they lack the information they need to drive their own daily improvement.
Solutions that include representative dashboards, scorecards and access to detailed interaction analytics encourage representatives to manage their performance, drive ongoing development and connect with peers to boost the entire team’s results. Gamification features let employees compare their progress to the rest of the team and challenge themselves to rise in the rankings. Empowering representatives can create a dynamic environment that leads to higher performance, more personal satisfaction and lower attrition rates. The resulting team continuity and stability drives quality.
Quality management is critical for your plan; your contact centre is a fundamental part of that effort. The performance of your representatives can drive your ratings and protect your bottom line. Or it can damage both. Empowering your representatives with the right tools and information at the right time can transform your contact centre from just a set of KPIs to measure into an indispensable driver of your quality metrics. All it takes is the right technology solution and your commitment to operationalise quality management in your member services teams.