How to Increase Your Health Plan’s Star Rating

Star Ratings are issued by The Centers for Medicare & Medicaid Services (CMS) each year to help the public make an informed decision when selecting a Medicare Advantage plan or Prescription Drug Plan. The Star Ratings are determined from a variety of metrics such as:

  • Health care quality
  • Complaints
  • Appeals turnaround time
  • Customer service
  • Foreign language support

The service provided by a health plan’s contact center continues to be given an increased weighting in the Star Rating calculation. As a health plan administrator, it has never been more important to ensure that your contact center is delivering excellent service to your members. Today’s health plan members expect the same level of customer service that they have grown accustomed to with top-tier service providers like Amazon. To meet the demand of today’s health plan members, your contact center needs to be equipped with the following key components:

1. Multi-Channel Communication

    Today’s health plan members want to connect with customer service representatives in a variety of communication channels such as email, phone, webchat, and SMS text. Delivering seamless multi-channel communication is becoming a member expectation, and shortfalls in emerging channels can prompt members to score your health plan negatively on ‘ease of business.’

    2. Virtual Queue

      Long customer service hold times are a common cause of frustration for health plan members, especially if the member has to stay on the line to remain in the queue. There are some best practices that your health plan should have in place to manage customer service queues. First, we advise providing an estimated wait time for the caller to be connected with an agent. Providing the estimated wait time sets expectations and reduces the anxieties associated with uncertain wait times. Secondly, we advise implementing a virtual hold queue. A virtual queue allows callers to hop off hold and continue with their daily tasks, which shrinks the perceived wait time.

      3. Convenient Hours of Operation

        One way to set your health plan apart from the competition is to offer the flexibility of extended business hours. Evening and weekend customer service hours allow your members to access their benefits at a time that is convenient for them. Offering convenient hour of operations can improve your ‘ease of business’ member survey scores.

        4. Foreign Language Support

          Health plans are graded on foreign language support and this grade ultimately impacts the Star Rating of the health plan. Your health plan should evaluate the demographics of its membership and service area to determine which foreign languages to prioritize, but at a minimum your call center should support Spanish. Foreign language customer service allows members to feel at ease while speaking to a representative in their native language about their needs or issues.

          5. High Service Level KPIs:

            Tracking service level KPIs enables your health plan’s member services team to monitor the member experience in real-time and to make on the fly adjustments. Below are three key performance indicators that the contact center team should monitor closely:

            • Abandonment Rate – If inbound service queues build up and cause long wait times, members can become frustrated and abandon their service calls before reaching an agent. Abandonment rate should be at or near the top of your list of KPIs as the abandonment rate is a close indicator of negative member experiences. Abandonment rate can be evaluated on a weekly or monthly basis, but monitoring this KPI at the intraday level will provide immediate alert to peak queue periods. 2.5% or less is a good benchmark for abandonment rate at the monthly level.
            • Grade of Service – Grade of service describes the percent of calls answered within a specified period. We recommend a grade of service of 80/30 which means 80% of the inbound calls are answered by a live agent within 30 seconds. Grade of service is a useful metric to evaluate the timeliness of phone support on average over a week or month.
            • First Call Resolution – Member service agents should be well-trained and equipped with intuitive customer information systems and knowledge base functionality so that they can quickly and accurately resolve member inquiries on the first contact. 95% is a good benchmark for first call resolution rate.

            6. Contact Center Quality Assurance Program:

            A well-developed quality assurance program is critical to delivering service excellence to your health plan members. Below are three important features of a top-notch call center quality assurance program:

            • Call Calibration Sessions – Call calibration sessions are the primary way to evaluate your contact center’s customer service quality with real member interactions. We recommend your management team (or dedicated quality assurance team) take a random sample of calls to listen and evaluate each month.
            • Speech Analytics – Today’s best member services teams deploy specialized software, speech analytics, to automate some of the quality assurance workflows. Speech analytics software can evaluate 100% of member interactions and measure sentiment, highlight key phrases, and identify areas of concern or success.
            • Agent Coaching – It’s not enough to just identify and report on call quality, your management team must take examples from call reviews and coach agents on ways to improve the member experience. Call review scorecards can be used to communicate areas of strength or weakness to service agents. For areas of weakness, we recommend roleplaying specific scenarios of weakness or difficulty. Coaches should model the appropriate response or scripting and let agents practice outside of the live call environment to gain proficiency and confidence.

            TAKE ACTION

            If you are looking to improve your health plan’s Star Rating by increasing customer service survey scores, you should consider

            Contact Center Outsourcing for Healthcare Plans


            Outsourcing Open Enrollment for Health Plans.


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