Moving Beyond Speed to Compliance, Trust and True Performance
Why Accuracy Can No Longer Be an Afterthought
For years, Medicare Advantage (MA) call centers have measured their success against two benchmarks: Average Handle Time (AHT) and First Call Resolution (FCR). These metrics still matter, but they no longer tell the full story.
In today’s environment, where every member call is recorded, CMS regulations grow more stringent, and member trust hangs in the balance, accuracy has emerged as the most important KPI call centers can track.
Getting a member off the phone quickly means nothing if the information provided was wrong. And resolving a question on the first call doesn’t help if the answer was inaccurate and the member finds out days later that their coverage was misrepresented.
The stakes are too high for carriers to treat accuracy as an assumed outcome of training or quality assurance. Accuracy must be measured, managed, and prioritized as a KPI in its own right.
The Compliance and Trust Equation
Medicare Advantage carriers operate under one of the most heavily regulated environments in healthcare. Every call is subject to audit. Every misquote risks not only fines but also reputational harm.
Consider the regulatory requirement that 80% of calls must be answered within 30 seconds. That metric is easily tracked. But what about the accuracy of the answers given in those calls?
Compliance risk: If a rep misquotes a benefit, say, a deductible, prior authorization requirement, or drug tier cost, that’s a compliance breach. CMS doesn’t allow for “close enough.”
Member trust: When beneficiaries get conflicting answers to the same question from different reps, trust erodes quickly. It only takes a few bad experiences for members to consider disenrolling.
Operational performance: Inaccurate answers create repeat calls. A member hangs up with one rep and calls back 10 minutes later to verify the information with another. Each new call adds costs and clogs queues.
In short, inaccuracy multiplies risk, costs, and dissatisfaction.
Why Accuracy Is Under-Measured Today
Most call centers rely on traditional QA processes, which review only a small sample of calls, often 1-3% of total volume. These spot checks may reveal general trends, but they do not ensure accuracy across the board.
This creates a dangerous gap:
Compliance requires 100% accuracy.
QA verifies only a fraction.
It’s no surprise then that repeat calls are common. In one analysis, a significant share of members contacted their carrier multiple times with the same question, receiving different answers each time. That’s not a training issue alone; it’s a systemic measurement issue.
Proof That Accuracy Drives Performance
When ServiceSense was deployed at a Fortune 50 carrier, the results spoke for themselves:
Accuracy improved 15%, reducing compliance exposure.
First Call Resolution increased by 24%, as members received consistent answers the first time.
Average Handle Time dropped by two minutes per call within the first three months.
Member satisfaction rose by 10%.
These outcomes are not coincidental. Accuracy directly fuels the KPIs carriers already care about: AHT, FCR, satisfaction, and compliance. By elevating accuracy to a KPI, carriers unlock measurable improvements across the board.
The Member Perspective: Accuracy Equals Respect
It’s worth pausing to consider this from the member’s point of view.
For seniors and people with disabilities, calling their plan is often stressful. They may be confused by dense plan documents, concerned about out-of-pocket costs, or worried about losing coverage for a necessary procedure. When they reach a rep and receive a clear, accurate answer, the relief is tangible.
Providing accurate information is both a compliance requirement and a sign of respect. It’s proof that the carrier values the member’s time, health, and peace of mind. And in an industry where retention is fragile, that respect can be the difference between loyalty and disenrollment.
Accuracy and Compliance in an Evolving Policy Landscape
The policy environment is reinforcing this trend.
CMS scrutiny is intensifying. The 2024 and 2025 Medicare Advantage Final Rules specifically target deceptive or misleading communication and require plain-language, accurate disclosures.
Aggressive marketing practices are under fire. Investigations by the Senate Finance Committee have spotlighted cases where beneficiaries were steered into plans that didn’t meet their needs, due in part to misrepresentations by agents and brokers.
Compliance expectations are rising. Carriers are being held responsible not only for their own staff but for downstream marketing partners and third-party vendors.
The message from regulators is clear: accuracy is not optional, it’s central to compliance.
Why Traditional Systems Fail on Accuracy
The root problem in most call centers is the reliance on outdated workflows:
PDF overload: Reps flip through 50+ page summary of benefits documents, sometimes across multiple plans, while members wait.
Fragmented sources of truth: Key benefit information may be scattered across memos, errata, and different internal systems.
Training burden: Reps are expected to memorize and internalize complex plan rules, even as turnover runs as high as 18% annually.
These conditions all but guarantee inaccuracy. Even the most diligent rep will struggle to provide consistent answers when the system itself is designed for errors.
An Accuracy-First Model with ServiceSense
ServiceSense was built to solve this exact challenge.
One source of truth: All plan information is modeled into a plain-language database. No more flipping through PDFs or piecing together answers from multiple sources.
Real-time updates: Year-over-year plan changes, drug cost adjustments and subsidy impacts are instantly available to reps.
Intent recognition: Reps can use plain-language terms and receive accurate, relevant answers.
Scalability: Seasonal hires can be trained faster, with less risk of compliance breaches, because the system provides guidance on demand.
In practice, this means a rep can answer a member’s colonoscopy coverage question in seconds, accurately quoting co-pays, authorization requirements and exclusions, all pulled directly from the plan’s benefits
From Reactive to Proactive: Making Accuracy a KPI
Carriers don’t need to abandon traditional metrics. AHT, FCR, and satisfaction will always matter. But by explicitly tracking and prioritizing accuracy as its own KPI, carriers can transform their call centers:
Measure accuracy directly. Use QA not just for compliance sampling, but to monitor systemic accuracy rates across reps and teams.
Tie accuracy to outcomes. Show how improvements in accuracy correlate with reductions in repeat calls, drops in handle time, and higher satisfaction scores.
Reward accuracy, not speed alone. Create incentives for reps who consistently provide accurate information, not just quick resolutions.
The result is a shift from reactive QA to proactive performance management.
Looking Ahead, Accuracy as the Competitive Advantage
As Medicare Advantage enrollment grows, already covering more than half of all beneficiaries, competition among carriers is fierce. Differentiation increasingly comes down to the member experience.
Carriers that treat accuracy as the new KPI will stand apart. They will:
Reduce compliance risk.
Increase member retention.
Improve operational efficiency.
Strengthen trust and reputation in a crowded market.
And they will do so in a way that aligns with both regulatory pressure and member expectations.
For carriers preparing for the next Open Enrollment Period and beyond, the time to elevate accuracy as a KPI is now.
Ready to Put Accuracy at the Center of Your Call Center Strategy?
ServiceSense provides your reps with a single source of truth, delivering plain-language, CMS-compliant answers instantly, so members always receive accurate information the first time.
Schedule a demo with our team to see how ServiceSense can help your call center improve compliance, reduce handle times and enhance member trust.
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