New ratings methodology has raised the bar for healthcare Star success, so it’s a good time to redefine what high Star ratings means to the members. This means connecting the dots of experience for satisfied members and true value creation for respective Medicare plans. Health plans can meet upgraded expectations with focus beyond customer service—as supported by healthcare domain knowledge and a high-touch experience across three critical areas: Claims, Medical Management, and Provider synergies.
Claims Knowledge
The customer journey to enhanced Star ratings relies on one often considered behind-the-scenes service area: Claims. The front lines of optimized customer experience are bolstered with claims excellence rooted in proficiency that spans Medical, Dental, Vision, and Pharmacy claims type. Multi-platform expertise covers key platforms, for example, Facets, Amisys, QNXT, Metvance, HealthRules Payor. The order of the day is how all processes—from digital mailroom, intake, adjudication, and claims rework to grievances and appeals are efficiently managed with tech enablement.
Undoubtedly, Claims is a central touchpoint—a bottleneck or a gateway to optimized payment and Star ratings. In fact, claims payment is probably the most pivotal leading measure for Star success.
Healthcare services experts with significant claims expertise bring an essential knowledge of the lifecycle for fast, accurate claims payment—a primary concern for providers and members. On-time and precise claims adjudication is highly important to a strong Star rating, for decreased provider abrasion and improved member satisfaction.
With health plans keeping the member at the center of the mission, healthcare services partners can help by addressing the issue at the heart of member experience: claims. Health plans that get claims payment right get a leading member satisfaction driver right, as well.
Medical Management
Clinical processes aligned to the member/patient experience are central to experience excellence. These functions include Utilization Management, Case Management, Population Health, Quality of Care, Clinical Denials, and Prior Authorizations. Today these service areas are bolstered by actionable data, predictive analytics, and robust technology like AI automation. Clinical disruption to optimize experience includes areas like high-impact Prior Authorization, bolstered with automation and real-time determinations, as well as an analytical approach to flag clinical decisions that need priority nurse review. The algorithmic decision support can identify high dollar clinical usage patterns, FWA patterns and CPT conversion/alternative treatment. Traditional, siloed UM programs are not adequate to meet current market conditions: a high-cost clinical resource pool and financially pressured payers and providers.
Experts like healthcare services partners have the combined digital solution and skillset: experienced clinicians supported by AI workflows to effectively manage the process and cost. Backed by process re-engineering, automation, and digitization, tech-enabled prior authorization processes will ease provider burnout and change the perception of this process. With clinical knowledge to address appropriateness of care, member satisfaction will lead to a stronger Star result.
Provider Synergies and End-to-End Understanding
The healthcare industry has experienced unprecedented change in recent years. Technological efficiencies and strategic service offerings, value-based care initiatives, and federal and state mandates have converged with the goal of creating a system that is patient-centered and outcomes based, while also lowering the overall cost of care.
More importantly, payers and providers are increasingly transparent and aligned toward better patient outcomes. As one example, the soon-to-be-enacted Interoperability and Prior Authorization Final Rule bridges gaps between payers and providers and aims to shorten the timeline for the prior authorization process to as little as 72 hours for urgent requests for individuals who get their health insurance through Medicare Advantage by automating some of the processing of the requests. This results in faster and improved care—as patients who receive an authorization while they’re still in the provider’s office are more likely to follow through with the recommended treatment.
This paradigm shift has made it inevitable for healthcare stakeholders to collaborate. Health plans need to prioritize the provider perspective and understand their core focus—so they should be less burdened with documentation, administrative services, and tangential processes like claims. It’s key for plans to remember that the provider is also a customer, just as the member—and with focus on the patient/member, Star ratings will increase.
Today’s payers and providers are increasingly transparent and aligned toward better member-patient outcomes. The right healthcare services partners—with expertise across the end-to-end member ecosystem from claims, clinical, and customer service—are ideally suited to help plans achieve better Star ratings.
Srikanth Lakshminarayanan
Srikanth “Sri” Lakshminarayanan is Senior Vice President, Center of Excellence for Healthcare Engagement Services (HES) at Sagility,a global leader in business process management and optimizing the member/patient experience. In this role, he leads the day-to-day call center practice and strategy for Sagility. He has more than 20 years of experience steering customer experience success for healthcare organizations.
