Healthcare and Life Sciences

3 ways the contact center has become the hub of health plan member experience

Jim Burke

By Jim Burke

0 min read

Health Plan Member Experience

How a differentiated member experience can drive value for payers.

After 18 months filled with headlines on the massive changes to how people interact with health information, virtual care and telehealth technology—and emerging models of care—it might seem that healthcare payers were left mostly unimpacted beyond a reduction in elective procedures and expanded COVID-19 benefits. 

But health plans and managed care organizations know the opposite is true: like all of healthcare, there have been dramatic shifts in how consumers interact with their health insurance, including an acceleration of longstanding trends and rising expectations driven by the pandemic. 

Recent surveys of Medicare Advantage and commercial plan members give us a sense of the scope of these changes. The rise in adoption of virtual care and digital health tools in 2020 across all payer markets presents a unique challenge and opportunity for plans.

A record 32% of commercial plan members engaged with their insurers on a digital channel like text or chat last year, and consumer expectations for healthcare have shifted to expect “Amazon-level” convenience and connectedness

Organizations that can deliver a member journey that is on par with what consumers get in other industries can differentiate from their peers, while payers who expect to revert to a pre-pandemic communication status quo will be left behind. 

That means the primary interface points between members and plans must become synchronized, personalized, and convenient, starting with the hub: the contact center.

3 key ways a differentiated health plan member experience will drive value for payers.

1. Unifying the member journey.

As plans roll out apps, portals, chatbots, and other digital engagement tools to meet health plan member preferences, they introduce new complexities and potential challenges to the member journey. 

From the time that a new member is acquired, through annual enrollment periods, episodes of care, billing, and management of chronic conditions, payers often use a wide range of technologies to automate interactions or support self-service. These point solutions often integrate poorly with one another, if at all, and are designed to be very good at addressing a very specific part of the member experience instead of supporting a connected journey.

Leading payers are using the contact center as the natural point of orchestration for the member journey. It makes sense: when a chatbot cannot (or should not) answer a member question, if a member has a concern with information found in a portal, or if they simply prefer to “talk to a human”—the contact center often sits in a central role of supporting digital channels. 

Using an open and cloud-native contact center solution that integrates with CRMs, EHRs, and various point solution APIs helps turn it into a command center for member interactions, where agents can quickly and easily see an accurate view of how members have engaged across all channels. 

Platforms that support chatbots, virtual agents, and omnichannel engagement natively allow for a reduction in point solutions as the contact center takes on a broader range of touchpoints than live calls. This speeds interactions, improves member experience, and enables agents to play a more effective role in the evolving member journey. 

2. Orchestrating health plan member outreach.

Traditional payer-member communication is often a combination of one-way outbound communication of required information and benefits education and inbound fielding of member questions and concerns, with the interactive engagement in care management reserved for higher-risk members. 

A combination of technology improvements and evolving member channel preferences has created opportunities for plans to become more proactive in engaging members in dialogue. 

Over 92% of Medicare beneficiaries own cell phones—an all-time high, according to Pew Research—and a stunning 62% of Gen-Z health plan members engaged their insurers digitally at least once in 2020.

Health plans have been able to send bulk text messages and emails for years, but may have avoided doing so for fear of being seen as spam. 

Three key strategies have emerged to avoid the pitfalls of mass member outreach:

  • Personalized content. Payers know they must make touchpoints relevant and tailored to the individual. An event-based management system for proactive outreach is essential, so that members can be segmented and messaged based on their individual preferences, health status, location, or other key data to ensure the right outreach goes to the right member.
  • Interactive outreach. Outreach must be interactive when using inherently two-way channels like SMS, voice, and chat. Utilizing chatbots with natural language processing (NLP) that is trained to listen for healthcare terms is critical to avoiding member frustration.
  • Staff support. Payers know that any automated interactions must be supported by human staff for the inevitable escalations, difficult questions, or frustrated members. Empowered contact center staff that can take over automated conversations via smart routing can add tremendous value as they focus on conversations where they can help members the most, while members self-serve the simpler transactions.

3. Driving higher quality ratings.

When thinking about the return on investment for member satisfaction, payers usually focus on member acquisition and retention. And while those are still vital goals, payers are increasingly seeing satisfied members as a key standalone goal. This is especially clear in the regulated U.S. market of Medicare Advantage. 

The Centers for Medicare and Medicaid Services (CMS) will release their Star Measures based on the 2021 Medicare CAHPS survey that quadruple-weights the Patient’s Experience and Complaints measures, making member satisfaction the single most important component of the rating. Every MA plan knows that achieving and maintaining high Star Ratings is essential to success and sustainability in the market, making this shift a major focus for plans.

While there is a direct Stars measure for Customer Service that hinges on how a plan’s contact center meets member needs, there are other 4x-weighted measures that the contact center also impacts. 

Agents often assist with coordinating access to care for many members, and are often called upon to aid in managing member confusion around specialist referrals. That makes the Getting Needed Care and Getting Appointments and Care Quickly measures both important for plans to consider optimizing their contact centers to support. 

AI-powered agent assistance to access knowledge base articles or get shortcuts to relevant CRMs or claims systems can help make the difference between a member leaving a call feeling supported or more confused than when they started. And a robust quality management system for the contact center itself is vital to maintaining service levels that members will remember if and when they receive a CAHPS survey. 

As member attitudes and preferences towards engaging with their plans shift, so do payer contact centers. Thankfully, the technology and best practices exist for health plans across markets to meet and exceed expectations and turn the contact center into a strategic differentiator. 

Talkdesk supports leading payers delivering a reimagined member experience every day. Watch this webinar with Ed Marx, Chief Digital Officer at Tech Mahindra Health & Life Sciences and former CIO of the Cleveland Clinic, and Greg Miller, VP of Healthcare & Life Sciences at Talkdesk, to learn more.

Patient Experience Reimagined


Patient experience reimagined


Jim Burke

Jim Burke

As Talkdesk's Manager for Healthcare and Life Sciences Marketing, Jim Burke is focused on helping healthcare organizations deliver better experiences for their patients and members through thoughtful and transformative technology solutions. He lives in his hometown Los Angeles and is fueled by coffee and Lakers basketball.