Healthcare and Life Sciences

Three ways the contact center will impact health plan quality ratings in 2022

Jim Burke

By Jim Burke

0 min read

3 Ways The Contact Center Will Impact Health Plan Quality Ratings In 2022

How health plans can achieve and retain high ratings through member experience.

Health plans’ 2022 will be a year defined by member experience. Driven by the evolution of consumer preferences and expectations, plans are looking to evolve the member journey to stay competitive. Our research showed that 78% of plan members call their most recent experience with a payer suboptimal.

In addition to market forces, there are higher regulatory stakes for member experience in 2022 than ever before. 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, the patient experience, complaints, and access measures will combine for 57% of overall Stars ratings for the 2023 ratings, based on data gathered this year.

There are 16 measures of the Stars ratings that fall into these two categories, and half of them are determined by the MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. CMS assigns an annual Star rating to MA plans to indicate their quality compared to other plans. Consumers use the Stars ratings to choose a plan, which impacts a plan’s growth and retention, and critical Quality Bonus Payments depend on them. With the change in Stars calculations, payers have a huge opportunity to win by offering differentiated services that delight consumers.

The contact center has become the hub of the health plan member experience. The member journey has shifted dramatically, and the topics and channels that consumers expect to engage upon with their health plans have broadened. The contact center sits at the nexus of proactive and inbound member conversations across those channels and topics, placing it in a strategic position to drive success in the member experience. Here are three ways your contact center can make the difference for health plan quality ratings in 2022:

Creating A Better Way For Health Plan Member Experience


Creating a better way for health plan member experience

1. Leading payers will use the contact center as a synchronized and seamless front door during and after open enrollment.

Payers know that they are in a vital period for the member experience. New members are onboarding, while others are still thinking about their decision to remain in their plans. There are numerous outbound communications required by either CMS or established best practices, combined with a spike in inbound member inquiries and requests for help navigating their benefits.

Consumer preferences for self-service channels have grown across age groups, including in the vital 65+ segment. But members still might be less confident in navigating information from their health plan and can be more likely to trust a human being over the phone, especially after trying to self-serve information and finding it confusing or not relevant to their needs.

Consumers are frustrated by call centers when they need to start from scratch and repeat their story each time they engage with the plan—this makes their experience needlessly complicated and time-consuming. Leading plans will leverage technology to integrate into CRM, claims systems, EHRs, or other systems of record to pull member information together into a single view. Their agents will have a unified view of context from previous interactions, claims history, and other information to use during their conversation. This context-rich and streamlined process helps the agent deliver a higher level of customer service and leave the member feeling that their experience was handled in an efficient, yet personalized way. This becomes important if a returning member gives a CAHPS survey evaluation in the March-May period on whether necessary information and help are always, usually, sometimes, or never given by their health plan.

2. Plans will find smarter ways to use automation in member interactions.

At a time when member experience is so important, there is a temptation to avoid anything that resembles AI and automation, to maximize the human touch that is often critical in healthcare. But this is a false binary: members expect convenient self-service and the best live agent conversations are supported by powerful AI that helps staff tailor the conversation and focus on applying that human touch.

And at a time where burnout and turnover in contact centers are higher than ever, intuitive AI tools to analyze conversations and guide staff to answers as they speak or chat with members can be vital to helping members feel that they’re dealing with a capable and caring organization. Innovative plans are using artificial intelligence to power chatbots that have natural language processing trained to understand healthcare-specific phrases and that listen for key terms when interacting with members.  And when members need to escalate to a human on chat or the phone, the context of the bot conversation can follow them to the next touchpoint, reducing frustration.

3. Top health plan contact centers will join those other industries in becoming more proactive, omnichannel, and available.

Health plans need to drive outcomes by engaging on their members’ terms, which involves meeting the member where they are with their preferred engagement modality. Plans that prioritize member experience measures are ensuring key self-service functionality, like checking balances or searching formularies, is possible across channels at all times. And while payers have used proactive outreach to drive positive quality results in HEDIS and medication adherence measures for years with targeted reminders, plans should now adapt outbound communication to reflect the CAHPS survey’s importance.

Sharing the good news, like a positive formulary change, a new supplemental benefit, or an expanded network in a member’s town carries a stronger ROI for plans than ever before. Just as precise segmentation and deep personalization is the key to closing gaps in care for HEDIS, members will only appreciate proactive outreach around improving experience if it’s tailored and relevant to them.

These conversations, especially when automated voice or text, should be tightly integrated with contact center data to avoid over-messaging and tailored to members that may have expressed negative sentiment in their last call to the plan, for example.

A focus on delivering an optimal patient experience through the contact center will be key to improving health plan quality ratings.

Talkdesk works with some of the most innovative payers in the industry to deliver these strategies (and more) to build better connections with members. Learn more about our work with payers, or see our latest research on health plan member experience.


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.