Improving the member experience is a top priority for leading health plans, yet friction across payments, regulatory compliance and system integration continues to stand in the way.
The most effective approach: methodically evaluate each stage of the member journey and add an orchestration layer to existing information systems.
To learn more about how health plans are working to improve their member experience, Becker’s Healthcare recently spoke with Robin Opperlee, vice president of marketing at CSG.
Note: Responses have been edited for length and clarity.
Becker’s: Health plans are often compared to consumer tech companies when it comes to member experience. From your experience, what are some of the biggest misconceptions behind that comparison, particularly given the regulatory and operational realities that payers face?
Robin Opperlee: Businesses of all kinds must deliver the seamless experiences that consumers expect.
The reality for health plans, however, is that the member experience includes extremely complex financial journeys like claims, payments and prior authorizations that can generate confusion among members.
Better communication and easier payment methods can minimize this, but payers must keep information-sharing regulations like HIPAA in mind. In addition to regulatory compliance, it’s important to consider business and technical challenges.
Health plans should tie smooth communication, easier payment options and more personalized experiences back to operational and financial outcomes like cost-to-serve, time-to-payment and traditional engagement scores.
Q: There’s a perception that member engagement primarily sits within marketing or customer service. But some of the most significant friction moments occur around financial interactions. How can payers rethink communications across these touchpoints to create a more seamless member journey?
RO: Payers must think about the member journey from end to end. If health plans look at the member journey only from a marketing or customer experience perspective, they miss critical areas that can cause friction. For example, bills and payments tend to be high friction points.
An important strategy is to map key touchpoints and connect all the critical systems that can create a seamless experience. This solves member problems and reduces operational costs.
First contact resolution is very important; plans can achieve that by pulling systems together. CSG maps all relevant member touchpoints , so that information is provided to whoever is trying to solve the member’s problem . For example, if you call your insurance provider about a confusing bill, the experience will be much stronger if the rep already has the claim open and can explain the exact line-item adjustment that corrected the balance. Serving up the right context really helps to deliver a positive member experience.
Q: Regulatory requirements around HIPAA, PHI and consent are often seen as barriers to proactive, personalized outreach. How can health plans still deliver relevant, timely communication while staying within those constraints?
RO: When health plans evaluate the overall member experience, they obviously must consider HIPAA, PHI and consent constraints — and frame what “good” looks like based on the requirements for handling sensitive information. Safe, compliant data handling is a critical element of building customer trust and delivering positive member experiences. To deliver on these objectives, it’s often easier for health plans to partner with a third-party vendor that’s committed to the highest standards, rather than trying to build compliant data-handling capabilities in-house.
It’s also important for health plans to work with members up front to capture consent and contact preferences, so that communication can be personalized and proactive. At the same time, health plans must direct members to secure portals for sensitive information.
Q: Many payer organizations assume that improving member engagement requires replacing core systems. What role can orchestration layers or even event-driven communications play in helping health plans modernize experiences without a full technology overhaul?
RO: At CSG, we’re really proud that our tools don’t require organizations to rip and replace their existing systems. CSG sits alongside a payer’s existing software, pulls data from those solutions and orchestrates it in real time. This type of orchestration layer avoids costly system overhauls and technology migrations.
We recommend starting small. Pick a member journey that needs to be fixed and prove it out. Orchestrate the experience, learn from it and then move to fixing something else. When you have a proven example of how orchestration solves member journey challenges and helps the business financially, it’s easy to demonstrate ROI.
Q: When health plans invest in improving member communications and engagement, how should they measure success? What operational or financial outcomes should leaders look for beyond traditional experience metrics?
RO: Experience metrics are important, but they are usually backward-looking and only show one slice of the entire member experience.
With orchestration and analytics, payers can see what’s happening in the moment and can quickly identify the best action to address member friction.
As leaders track operational outcomes, they need to determine whether they are reducing the cost to serve. Key questions include: Were there fewer repeat calls to the contact center? Was there improved call deflection or digital containment rates? Has there been an increase in payment velocity and a reduction in administrative costs? By looking at these factors together, health plan leaders can see how these journey improvements not only create a stronger and more trustworthy member experience, but also drive efficiency and sustainable economic value.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
