How Can a Healthcare Call Center Help Health Insurance Carriers Improve Their Star Ratings?


When Centers for Medicare and Medicaid Services (CMS) implemented the Five-Star Quality Rating System in October 2007, is intended to improve the quality of care and reinforce protection for beneficiaries. On a scale of one to five, these ratings measure how well a particular healthcare plan (payer) gives coverage to the members and meets federal guidelines and commendations on patient care and services.

The rating itself is based on the performance of 48 individual measures, 34 from Medicare Part C and 14 from Part D. Developed under the Affordable Care Act (ACA), the Medicare Advantage (MA) star rating scale measures how well plans perform in these categories:

  1. Outcomes
  2. Intermediate Outcomes
  3. Patient Experience and complaints
  4. Access
  5. Process

This rating system was charted by the CMS to help beneficiaries simplify the process of selecting the best healthcare provider as well as for allocating federal grants to top performing payers.

While the parameters for earning a five-star rating are stringent, making that coveted spot has its benefits. Healthcare plans with better ratings tend to interest more members, so there’s a built-in incentive structure to the rating system. Plans with five-star ratings also enjoy certain advantages, like being able to enroll members throughout the year, whereas, plans earning a four-star rating and above can enjoy a 5% bonus on the base rate along with a higher number of enrollments and a more significant rebate.

Therefore, it can easily be said that the star rating system plays a serious role in improving health insurance payers’ performance. MA plans that work to promote and improve their star rating can capitalize on the opportunity to develop better processes and thus, service patients more effectively.

There are a few concrete steps that a health insurance carrier can take to improve their ratings. Many of these steps involve partnering with an experienced multichannel multilingual healthcare call center like Ameridial that can provide high-quality customer support to their members via voice, chat, email, SMS, and IVR. Here’s how a healthcare call center can help a health insurance carrier improve their MA star ratings:

Encourage Plan Members To Utilize Their Covered Services

The healthier plan members are, the better the plan’s star rating. Therefore, health insurance carriers must encourage their plan members to use their covered services. For healthy members, this includes taking annual physical exams, preventive health screenings, and vaccines. For members with chronic diseases, administrators must encourage them not to miss a single scheduled doctor’s appointment and stick to the prescribed course of treatment.

It’s important to share information about the patient’s illness and provide tips on how to manage it most effectively.

How A Call Center Can Help – A HIPAA compliant call center can help healthcare administrators remind the plan members about their annual physical exams, preventive health screening, vaccines, and doctor’s appointment schedules. A call center can also be used to provide tips to plan members regarding how they can manage their illness effectively.

Give More Priority To The User Experience

These days user experience gets priority in every sphere of life, why should healthcare vertical be any different? The star rating system places significant importance on the experience of health plan members. Therefore, a carrier must work on improving member experience whenever possible. The member experience can be enhanced by offering an intuitive website and apps where members can pay their bills, schedule appointments, find in-network providers, file a complaint and get every information regarding their plan and coverage.

It will also be better to provide the members with omnichannel support so that they can use their preferred channel to reach the carrier and receive a seamless experience.

How A Call Center Can Help – While a call center cannot ensure the overall quality of a member’s experience with their health insurance carrier, a multichannel call center can help. By providing members a seamless experience across all channels, a call center can provide a consistently high-quality experience with every interaction. While customers may use self-service for getting information regarding their payment or plan, they may want to talk to a live agent when they face a complex issue.

Therefore, insurance carriers can team up with a multichannel BPO that has extensive experience serving the healthcare industry, and it’s members.

Customer Service

Customer service is a significant area of concern for star ratings. Administrators can improve this segment by offering online FAQs, chat support, email support, SMS support, and 24-hour voice support. Providing support through a variety of channels will ensure that the carrier is providing optimal customer service to members.

However, passive support will not be enough to improve their rating. Administrators will have to send text reminders regarding billing complete with the due date and the amount to be paid. Proactively mail them precise plan details and even send automated appointment reminders to live up to their members’ expectations.

How A Call Center Can Help – Health insurance carriers can hire an experienced healthcare call center with multichannel capabilities to provide the optimal quality support to its members. A call center can be utilized in providing proactive support to the members such as reminding them about their bill through SMS, emailing them their plan details or the list of in-network provider, reminding them about a scheduled appointment and sending them a link to reschedule their appointment whenever necessary,  or providing them with materials related to their query.

Apart from this, a call center with multilingual capabilities will also add value to enhance the star rating.  Such proactive supports and value-added interactions will ensure an improved CSAT level that can lead to increased brand loyalty among their existing members.

Growth in MA

From 13 percent in 2004, the number of MA enrollees increased to approximately one-third of all Medicare enrollment (about 20 million Americans) in 2017.  According to LEK Consulting, MA enrollment is expected to exceed 50 percent market penetration (nearly 38 million) by the end of 2025. With MA plans growing in popularity, more health insurance carriers look forward to improving their MA star ratings.

To get the best results, they should team up with an experienced healthcare call center with multichannel capabilities, like Ameridial, to provide their members with a high-quality seamless experience throughout their journey.