Customer service is the area of greatest weakness in overall enrollee satisfaction, even though Organizations have direct control over their customer service staff, regardless of the Organizations model. For instance, according to New Jersey Organizations Performance Report, the percentage of members who said they had no problem finding or understanding written information, getting needed help from customer service, and completing paperwork was on average 63 percent among eleven Organizations rated. The national average of the National Committee for Quality Assurance (NCQA) is 64.5 percent. It means that more than 35 percent of clients are not satisfied with the provided customer service.


Managed Care Organizations launch Quality Improvement programs, conduct studies and surveys, invest in Quality Assurance, and go through expensive NCQA ratings to prove to customers their excellence. In Managed Care business, good name and reputation mean increase in membership and larger profits. MCOs cannot afford to neglect their service quality. Often, the right software system makes all the difference in the healthcare customer service quality. From Aetna Annual Report: “We moved nearly all of our Organizations members onto a single technology platform, which will help us to operate more efficiently… At our service centers, statistics show that handling of customer calls improved significantly, despite a 25 percent increase in call volume.” PAIN ANALYSIS: NCQA issues the State of Managed Care Quality Report compiled from data submitted to the Quality Compass from over 350 health plans, covering over 60 million lives, measured against rigorous standards in the areas of: customer service and addressing member concerns, providing high credentialing standards of providers, responding to member and practitioner issues, and listening to and addressing feedback of new members. The report gives an insight into the dissatisfaction with managed care customer service:

  • 15 percent of respondents have problems with paperwork for their health plan;
  • 42 percent reported having problems getting necessary information from their plan’s customer service department;
  • 43 percent reported problems in either finding or understanding the information contained in their health plan’s materials.

Managed Care Organizations have a growing need for improvement in these areas. Organizations can have more control over the situation by regularly analyzing Customer Service performance measures reports. You should keep track of at least the following measures:

  1. Customers served per month
  2. Average number of complaints per month
  3. Number of emails processed per month
  4. Average wait time per call
  5. Number of one-and-done calls per month
  6. Average time per group enrollment
  7. Average time per account installation
  8. Customer satisfaction rating

QIEM HMOZ helps provide better service to groups and members during the enrollment process. QIEM HMOZ improves internal procedures to set groups up on membership and claims systems and provide ID cards to the members on a timelier basis. In addition, booklet inserts can now be issued to members to reflect mid-year benefit or eligibility changes rather than reissuing entire booklets. New member education becomes more efficient: welcome calls are made to new members to provide education about the health plan policies and procedures, explain the benefits, and answer questions. Welcome letters are sent to those members that were unreachable by telephone. Case study: Customer Service improved by new Call Center System

Minnesota-based Organizations provides health-care services, insurance, and Organizations coverage for over 660,000 members. The organization’s member service representatives are a critical point of contact for members with questions about coverage and care issues. In 2000, member service reps fielded more than 1 million calls. Just seven years earlier, the same number of reps handled between 198,000 and 200,000 calls at an average length of 4 to 4.5 minutes per call. At the same time, their access to information was insufficient. In the mid-nineties, reps relied on information from their legacy mainframe system, other single-point systems, and numerous reference publications to answer questions. Their cubicles were crowded with volumes of reference sources for answering questions. As part of its desire to provide improved member services and better internal communication, Organizations needed a new, integrated system to facilitate information exchange between all internal departments and eliminate duplication in job functions. A custom-built system was implemented to address these issues. Today, the service representatives still spend an average of 4 to 4.5 minutes on each call, however, now they answer more questions in that time, resulting in fewer repeat calls and more satisfied members. Service representatives provide members with more accurate information, and staff throughout the network spend less time adding and updating information. More than 1,000 Organizations employees now have access to the system, including the Organizations 100 service representatives.

Most Organizations still need a customized system that would allow the entire company, especially member service representatives, to access vital customer service information and details on members’ insurance plans. ADVICE: QIEM HMOZ state-of-the-art business information system gives you the ability to deliver excellent customer service to members, providers, employers, brokers, and other benefits consultants. QIEM HMOZ tracks a wide variety of enrollment and renewal info, plan designs, quotes and rates, member and broker data, leads and prospects, opportunities, and outcomes measures through an automated information system, enabling MCOs to conduct historical comparisons, trend analysis, and ongoing quality improvement. Not coincidentally, all Organizations clients got positive ratings by NCQA. One Demo is better than a thousand words, and one Design Audit is better than a thousand demos. We encourage you to follow our CRM proverb and take advantage of this opportunity.