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Artificial Intelligence: The Secret Sauce for Improving Medicare Member Satisfaction and CAHPS Scores

The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare Advantage (MA) Star measures are shifting and will be heavily weighted toward member experience. For 2021-2023, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey weighting moves from 22% to 32% and satisfaction is the single most important Star measure group. When combined with administrative measures, member experience accounts for 57% of Stars.

As we enter the CAHPS season, health plans will need to gather data to understand member perceptions about how well they have informed seniors about plan benefits, how well the plan met their needs, and overall satisfaction on many levels. In preparing for CAHPS season, it’s important for payers to understand some critical questions:

  • How are you enabling benefit sharing at the time of plan shopping and enrollment, to ensure the consumer selects the best plan based on their coverage need?

  • How will you engage with new enrollees to welcome them to your health plan and ensure they understand their benefits?

  • How will you continue to engage them to achieve satisfactory results?

A comprehensive, holistic Medicare member engagement strategy is critical for payers to succeed. Outbound campaigns and communications should engage and educate seniors from shopping, initial enrollment and onboarding, through annual enrollment. Essential to these communications is clear benefit and coverage information, detailed for full and accurate assessment based on the clinical status, pharmacy needs, provider preference, etc.

Payers can increase awareness by connecting seniors on any channel they choose and providing clear, accurate information relevant to their individual health status and benefit situation. For example, providing the right information on prescription benefit coverage information during a phone call not only improves access to needed drugs but also improves medication adherence and ultimately improves health outcomes. Enabling seniors to efficiently shop for the best fit Medicare plan by using a virtual agent, for example, is one way to create a great first impression and build brand loyalty. With the virtual agent, they can ask questions like “is my doctor in the network?” and then be guided to enroll efficiently and seamlessly.

Make Shopping for MA Plans a Breeze

According to a JD Powers report, despite a highly motivated customer base that wants to understand healthcare options, MA plans miss the mark in their communications and engagement strategies. “Members can shop and switch plans much more freely than with other types of health insurance coverage, and they tend to take a proactive role in seeking information about the best options for their unique healthcare needs. Against this backdrop, Medicare Advantage plans have a huge opportunity to increase member satisfaction, trust, and loyalty by providing them with more frequent and helpful information. Yet, few plans manage to get the communication formula right—a fact that has been amplified by COVID-19,” said James Beem, Managing Director of Global Healthcare Intelligence at J.D. Power.

In other words, starting with a great sales experience is the first step toward better ratings. And why not begin with offering digital solutions like virtual assistants/chatbots for MA plan shopping? Despite Medicare Advantage plan members being older, on average, than traditional commercial health plan members, more than 40% of Medicare Advantage members utilize digital means when gathering information regarding their health coverage (McKinsey Report). And digital engagement will continue to increase with the aging Baby Boomers and seniors spending a significant amount of time in front of screens.

Raise the Bar on Service to Drive Satisfaction and Trust

Every single interaction with a Medicare customer is an opportunity to create a delightful and meaningful experience, but stellar service levels require a focus on consistent, clear communication and an understanding for how satisfaction directly impacts your ratings. Overall member satisfaction increases 209 points (on a 1,000-point scale) when plans meet three key performance indicators related to information and communication (CMS/JD Powers): 1) Making sure members fully understand their out-of-pocket costs, 2) Providing health education, and 3) Delivering useful reminders for preventive services.

The sad news is that despite the significant positive effect on member satisfaction, just 15% of Medicare Advantage plans deliver all three information and communication performance indicators (JD Powers). We learned from various payer interviews that there are several root cause issues holding them back from achieving their member satisfaction goals:

  • Lack of an integrated service experience across channels. For example, when members interact with the payer’s online portal and don’t have the answers they need, they have to start over when they place the call.

  • Call center agents have too many screens and text to navigate for even the most basic questions about coverages. They also get bogged down with complex terminology.

  • Agents don’t have the ability to recommend the next best action from a benefit question, like helpful information about preventive services that are covered.

  • Online portals are static and don’t offer a conversational interaction that could potentially deflect a call while creating an engaging digital experience.

AI Technology Is the Power Behind Great Ratings

AI as a foundational technology strategy can unlock payer data and create one source of truth for benefit information, powering a consistent and accurate multi-channel member experience. Powered by expert modeling of plan data, benefit information can be readily available at the fingertips of the agent, whether live or virtual. Information that is easily accessible and presented in a simple and understandable fashion (i.e. without complex healthcare terminology and acronyms) is the backbone for success. High-impact customer experience touchpoints that have a greater impact on satisfaction scores can include shopping for a plan, picking a provider, understanding costs, or wanting to understand benefits.

Making benefit information available via smart conversational virtual agent chat allows these unique enrollees a consumer-centric engagement opportunity and information-sharing experience which they access in every other aspect of living and expect from healthcare. Having that same information detail available for an agent during enrollment allows consumer-centric shopping. For example, a procedure code breakdown of costs, by plan level, allows your prospective enrollee to make the plan selection which meets their needs and lays the foundation for satisfaction throughout the year.

Unlocking complex benefit information through foundational AI technology can create consumer-centric opportunities and help health plans boost risk-adjusted revenue, improve quality ratings, and increase member and provider satisfaction through sustained and consistent engagement.

Sensentia provides leading-edge healthcare AI software that creates a single source of truth transforming complex data into clear, instantaneous answers for health insurance members, call representatives and sales agents. To learn more, Schedule a demo today!





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