3 ways to reimagine the health plan member experience

The cascading effects of the COVID-19 pandemic have caused employers and health care organizations to innovate and adapt in response to evolving market needs spurred by increasing consumerism. The modern health care consumer wants it all: virtual care, telehealth services, and convenient customer support from both providers and payers through the channels of their choice.

Currently, members evaluate payers based on the various experiences throughout their journeys: from new member onboarding to prior authorization and claims processing, to searching for in-network care. Members expect most of these interactions with their health plan to be possible wherever, whenever, and however they choose. The pandemic accelerated an existing trend of consumers expecting more choices and getting the empowerment they feel in other industries.

As a result, payers are catching on. Almost one-third of commercial health plan members said in a recent J.D. Power survey that they connected with their health plans through virtual means during the past year, including via web, mobile app, or text message.

Still, despite this being the highest percentage of virtual connection between member and payer, health insurance remains one of the lowest-rated industries in terms of consumer satisfaction, J.D. Power notes. What is encouraging for payers is that the demand for and availability of modern customer support platforms provides an ideal business opportunity to increase both member engagement and brand loyalty. But offering lots of channels isn’t enough — members are looking for the seamless and tailored journey that they can support.

By establishing a platform that manages member interactions, one that is powered by artificial intelligence (AI) and automation, payers can offer members a synchronized, personalized, and convenient experience as they receive in more consumer-friendly industries like banking. An information and communications hub like this can also provide payers with a strong competitive differentiator.

Below are three ways a comprehensive member experience can support value for health plans.

1. Reach out to health plan members

It’s no secret that the health care industry has a longstanding reputation for slow adoption of technologies. The most obvious example is payer-member communications. These typically consist of a single, one-way outbound communication, usually either mail or email, with information regarding payments or benefits changes, and inbound requests from members to answer questions or raise concerns. Patient queries may come through phone calls, emails, texts, patient portals, or mobile apps.

Just as cloud-native digital platforms can unify the member journey, they can also transform the ability of payers to proactively engage members in dialogue by leveraging the same digital channels members use and prefer.

Using these digital channels to bombard members with the equivalent of spam, however, would be ill-advised and self-defeating. Rather, payers must tailor content to each member. This can be done through event-based management software that can segment member populations based on highly specific data points such as age, health status, location and channel preference.

Finally, automated interactions must be seamlessly supported by, and transitioned to, human staff when necessary. There simply are limits to the types of questions and problems that can easily be handled by bots. For those interactions that require escalation or human intervention, smart routing functionality can ease member frustration and empower live agents to provide better support.

2. Maintain high-quality ratings

Beyond keeping eyes on member acquisition and retention, payers are increasingly focusing on member satisfaction as a key performance metric to evaluate. This is a timely change in business direction as new regulatory modifications rolled out by the Centers for Medicare and Medicaid Services (CMS) will give additional weight to member experience measures when determining the CMS Star ratings for payers’ Medicare Advantage (MA) plans.

It’s critical for MA plans to both achieve and maintain high Star Ratings. McKinsey even calls MA plans “the fastest-growing line of business for many health plans.” Such a platform for handling these interactions can be an important factor in the ability of payers to maximize MA performance payments.

The right technology can promote payer engagement with members and ensure a smooth customer journey. This is crucial, as member attitudes and preferences continue to change regarding how they engage with their payers and are forcing health plans to either evolve or potentially risk losing business.

3. Make the member journey comprehensive

The copious number of digital engagement tools available to health care consumers includes mobile apps, online portals, chatbots, and other technologies. However, these tools are usually poorly integrated, or not integrated at all, and navigation becomes confusing for health plan members.

Considering the variety of platforms and channels used by payers to automate interactions and support member self-service, it shouldn’t be surprising that these point solutions make it challenging for members to navigate the system and receive the appropriate information when they need it. Ultimately, constant roadblocks could drive members to another health plan, especially for those who need regular or frequent contact with their health plans due to ongoing episodes of care or management of chronic conditions.

Major payers are beginning to use cloud-native digital platforms to orchestrate member journeys. These platforms serve as a hub for health plan member interactions by supporting omnichannel digital engagement. Additionally, the platforms can coordinate responses to member questions and requests through the channel preferred by the customer, including via live agent.

Ideally, a streamlined platform that integrates with CRMs and allows for cross-channel support can expedite time to resolution, improve the member experience, and enhance brand value.