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Contact Centers: The Foundation to Secure a CMS Five-Star Rating

Contact Centers and the CMS Five-Star Rating

The CMS Five-Star Quality Rating System, part of The Affordable Care Act, has brought quality measurement and improvement to the forefront of every Medicare plan’s action item list. And, with payment reductions quickly approaching, the quality bonus for a top Star Rating is unfolding as one of the best approaches to allow plans to continue offering attractive benefits and provider networks.

It is clear that a Five-Star Rating is critical to member enrollment, retention and satisfaction. However, what is underappreciated is the role a contact center can play in increasing this rating. A contact center can help to bolster the rating – not just through the Customer Service Domain – but by identifying strategic approaches to utilizing the contact center within each domain.

Utilizing DialAmerica Healthcare Solutions to Impact Your Plan’s Five-Star Rating

DialAmerica Healthcare Solutions uses a proprietary process of integration within each Five-Star Rating domain, utilizing the contact center to its fullest across all areas of the rating system. Through this integration, DialAmerica Healthcare Solutions is directly able to help bolster a plan’s Star Rating and is also an asset in providing a breadth of information from conversations (via 360 degree integration) that yield key data needed for CAHPS, HOS and HEDIS.

Here are just some of the ways DialAmerica Healthcare Solutions can help contribute to the Five-Star Rating for your Managed Care health plan:

Domains 1 and 2: Preventive Care and Managing Chronic Conditions
  • Contact Center Integration Approach:

    • Proactively reaching out to health plan members to schedule chronic care and routine screenings, vaccines and tests encourages preventive and chronic disease management.
    • Continuous customer interactions allow health plans to connect with beneficiaries in an efficient and effective manner, helping them build long-term membership.
  • DialAmerica Key Assets:

    • We implement a team of highly trained and skilled customer service agents who act in a concierge-style to conduct proactive outreach to high-risk members. This adds an additional layer of contact to ensure that preventive care is reached.
Domain 3: Perception of Quality: Ratings of Health Plan Responsiveness and Care
  • Contact Center Integration Approach:

    • Customizing integrated systems helps identify potential complaints before they occur and maximizes each interaction with a member or provider.
    • Facilitating outbound surveys of beneficiaries as well as providers encourages communication. Contact centers that work to build these active communication channels directly with beneficiaries and providers are better equipped to deliver meaningful customer messaging and customer advocacy.
  • DialAmerica Key Assets:

    • During each call, our agents specifically review member’s call history and use the interaction as an opportunity to address any issues. We ensure that anything brought to light during these interactions is followed-up on in pre-defined turn-around times. We consistently call members and speak with them 6-8 times per year rather than waiting for ANOC outreach to find out if someone is disappointed with the plan.
Domain 4: Health Plan Member Complaints, Appeals, and Choosing to Leave the Health Plan
  • Contact Center Integration Approach:

    • Limit complaints to the CTM by continually evaluating client programs and implementing consumer-facing changes based on the results.
    • Utilizing a high quality contact center sets the health plan apart from the competition in their service area and could potentially give the plan a year-round SEP. Plan member complaints are reduced and member retention is increased.
  • DialAmerica Key Assets:

    • Our contact center agents analyze all silos within the plan when interacting with a member or provider. We play a key role in the beneficiary appeals process in that we can provide detailed and accurate patient records and full explanations of the appeal circumstances. We implement strategic initiatives that directly impact member retention and limit plan member complaints.
Domain 5: Customer Service
  • Contact Center Integration Approach

    • Meeting customer needs is critical, and improving customer service is one of the least expensive and most effective means to improve margins, growth and in this case - retention.
    • Both customer service and retention are tied to every aspect of the relationship that a Managed Care plan has with its members – every telephone call, every email exchange, and every written communication.
  • DialAmerica Key Assets: Our key customer service and retention components include:

    • Helping callers quickly find care
    • Delivering accurate information to members when they call the health plan
    • Providing TTY/TDD services and foreign language interpretation
    • Providing interactions that are directly relevant to members
    • Bringing years of experience and best practices to achieve desired results in this domain

At its core, this rating system evaluation process highlights that having happy members results in having a higher star rating. In fact, according to data from the Medicare Rights Center, aside from coverage denials for medical services; provider access problems, misinformation and marketing conduct are the most prevalent reasons for a member to disenroll from a Medicare private health plan.* Moreover, acquiring new members is estimated at five-times the cost of keeping existing ones.

The bottom line is, those plans that understand how crucial the contact center function is will stay ahead of the curve in implementing a multi-angled approach to improving their Star Rating.

* Medicare Rights Center, "Why Consumers Disenroll from Private Health Plans" Summer, 2010

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