Appeals & Grievance Data is Critical in Identifying Changes to Enhance Member Satisfaction
By Laurie Delgado
As the health insurance marketplace becomes more and more competitive, insurers have become increasingly aware that customer satisfaction is often a key differentiator in distinguishing one plan from another. This is especially true in the Medicare arena as constricting CMS regulations, a consolidation of health plans and cross-over provider networks are neutralizing or minimizing the once traditional variances found in benefits and pricing.
Health insurance organizations that provide high-quality customer experiences can separate themselves from the competition, stake out a position of industry leadership, and even drive improvements in health plan performance. But to do so, they need to have reliable data that will allow them to measure enrollee satisfaction in ways that support such functions as strategic planning, marketing and quality improvement efforts.
To be sure, ours is an industry swimming in data. These include a variety of published surveys health plans often use to benchmark themselves relative to their competitors – including CAHPS surveys, HEDIS reports and Medicare STAR ratings. In addition, many health plans sponsor targeted member surveys that they commission through independent outlets. But what leading health plans are just now waking up to is that they already possess an untapped gold-mine of information that is waiting patiently to be accessed and leveraged for huge rewards.
That not-so-hidden treasure is found in Appeals & Grievance (A&G) data, where both members and providers have imparted a window into what they perceive to be negative experiences, outcomes or concerns. As health insurers strive to bring the voice of the consumer to the forefront of their decision-making process, the analysis of A&G data can be critical in identifying what changes must be made to enhance enrollee satisfaction. By understanding the issues and events that result in a negative member experience, and by making the commitment to take swift action to address and correct the root cause of the abrasion, organizations can repair the relationship, which translates into consumer loyalty, growth and member retention.
Make no mistake, consumer loyalty is what every health plan should be seeking and there is a big difference between a satisfied customer and a loyal customer. As Chip Bell, author and consultant in customer loyalty and service innovation once explained “loyal customers, they don’t just come back, they don’t simply recommend you, they insist that their friends do business with you.”
When analyzing A&G data, health plans need to ask themselves not only “how did this happen?” but how could it have been prevented? Often this calls for working to unearth any missed opportunities that could have prevented escalation – such as previous calls into Customer Service about same issue or duplicate grievances about same issue from multiple members. To aid in this analysis, plans need to capture additional data elements beyond those required for regulatory reporting. These might include vendor or delegate name, sales and/or customer service agent, method of enrollment, name of the plan a disenrolled customer exited to, policy or event that caused abrasion or number of previous contacts with the plan about the issue.
Digging deep to find the root cause of a complaint is a useless exercise unless the health plan makes a commitment to follow the evidence wherever it may lead. Correcting the problem, particularly a recurring one, may force the health plan to make some very tough choices and shake up their comfort zone. It may require updating policies, investing in training, dedicating additional resources, initiating contractual changes with vendors, issuing sanctions for failure to meet performance standards and even terminating existing contracts and relationships with providers, vendors agents and/or employees if that’s what it takes to turn the ship around.
All of this is hard work and requires a resolute commitment from leadership (often at the board level) that exceptional customer service is not just a “nice to have” but a “need to have.” It may also involve a paradigm shift in how many health plans view the role, responsibilities and important contribution of their appeals and grievances team. To be certain, A & G will never surrender its role as the department responsible for reviewing, analyzing, and processing reconsideration requests and customer complaints. But now the department should rightfully be looked upon as an equally important repository of valuable information that, if properly leveraged in a smart and actionable way, can lead to a decrease in complaints, an increase in member retention, higher CAHPS and survey scores, and increased revenue for the health plan. Those are the tenants of any sound business strategy. Customer satisfaction is the door in, and A&G data holds the key.
Vice President of Appeals & Grievances
Beacon Healthcare Systems
Laurie serves as the Vice President of Appeals & Grievances at Beacon Healthcare Systems. With more than 20 years of experience overseeing Medicare appeals and grievances for two of the nation’s largest and most highly respected health plans, she currently provides oversight of the company’s highly acclaimed Virtual Appeals Manager (VAM), the industry’s most intuitive and easy-to-use appeal and grievance tool.