The Balancing Act: Designing Consumer Experience to Fit your Financial Model

The ‘Age of the Customer’ has pressed most industries to redesign their customer relationship model to fit the needs and wants of an informed and involved patient. With retail, tech and airline industries paving the way, many healthcare providers and payers are on their way to connect to their customers on a more efficient, transparent level. On the other hand, to stay competitive, healthcare providers and insurers must weigh costs against the consumer experience, while also balancing privacy and security against ease of access and patient empowerment.

The answer to the cost-versus-experience conundrum lies in streamlining the support model for customers by eliminating the friction and waste that drives both cost and poor customer experience. In short, the more effort a customer must expend to resolve an issue, the more dissatisfied he or she will become and the more it then costs to support them.

From its experience of working with hundreds of customers, Alorica identified two fundamental steps to forming a streamlined customer experience model:

Step 1:  Analyze

By following common customer journeys through the healthcare system, providers can gain insight into which processes and technologies are critical to delivering a consistent and differentiated experience, one that instills loyalty and prompts members to advocate positively and publicly for a service or product.

Step 2: Focus on gaining insights

In 2015, Alorica studied the impact of claims handling on contact center volumes and customer satisfaction. Not surprisingly, the top drivers of contact activity and repeat contacts were processing delays, disputed claims and resubmitted claims. The study found that the longer a claim stayed open, the higher was the likelihood of a repeat contact, and the less likely the survey response was to be positive. In addition, the likelihood of a positive survey outcome decreased in relation to the number of submissions / resubmissions required to close out a claim.

Streamline the Service Model

With this knowledge, Alorica qualitatively mapped out the customer journey, helping shed light on the emotions and the perception of effort experienced along the way. These insights helped pinpoint the root cause of delayed and resubmitted claims, and led to the discovery of impacts on members and providers. Here are the insights of downstream impacts:


• Call repeatedly, and with increased frequency, because they are pressured to pay bills every thirty days.

• Bounce between the payer and provider with no resolution.

• Must pay out of pocket, in some cases until the claim is resolved; getting reimbursed is difficult and often results in an increase in calling effort.

• With fewer options, they perceive less value for price, poorly affecting the health plan company’s marketability and renewal rates.

• Complain online, to employers, etc., influencing future renewals along the way.


• Call because they need claims paid, and call volume increases if they can verify benefits in advance.

• Become frustrated, and their desire to advocate for the member wanes, resulting in the member having to expend more effort to resolve claims.

• View dealing with the insurance company as too much effort, with some opting to no longer accept patients covered by the insurance company.

As with the other industries, cost and experience were heavily impacted by resolution, effort, and emotion. Once the root causes were uncovered, however, we then could recommend the appropriate actions to fix the breakpoints:

• Automation of processes and electronic submissions to speed claim submission and processing.

• Education for providers on avoiding common filing errors that cause delays, reducing the need for resubmission.

• Scalable staffing for claims adjusters to meet variable demands in volume.

• Education for customers on standard processing timelines to reduce the likelihood of calls occurring before claims could reasonably be processed.

• Real-time communication with providers on current averages to set appropriate expectations.

• Visibility for front-line agents into pending claims and average time frames to reduce call transfers.

The current trend of a customer-centric delivery of healthcare services shows no signs of slowing down. Customers will continue to expect fast and accurate resolution, easy access to information and services, more choices and increased transparency. Companies that can deliver on these expectations are set up to win in the ‘Age of the Customer.’

Greg Hopkins is Chief Client Officer for Alorica.


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