CHAPTER 20:
MEMBER SERVICES

Julianne
Gardner
Jaivon Lewis
Jake Wilson

INTRODUCTION
 What experiences have you had with calling member services departments?
 Were these experiences positive or negative?
 As the consumer, how do you think member services departments could better serve you?

WHAT ARE MEMBER SERVICES?
 “Customer Services Function” – off er guidance for navigating the health care world.
 Fundamental delivery approach for member services is through a customer interaction center
 Supports inbound inquiries across a broad array of media, blended with outbound contact and outreach transactions.

 Enables the member to communicate directly with his/her insurer
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Enrollment
Complaints, payment issues, etc.
Claims processing
Assistance in procuring coverage/care.

MEMBER SERVICE ENVIRONMENT
 Customer Interaction Centers
 30-400 customer service representatives (CSRs)
 Located with other “back-offi ce” functions (claims payment, provider services, enrollment, billing, etc.)

 Center locations:
 Less expensive areas.
 Educated & available labor pools with minimal competition for employees.
 Communities that off er the payer incentives for stable, long-term job opportunities for their citizens.

 Outsourcing/Off -shoring calls

SUPPORT FUNCTIONS & METHODS
OF ACCESSING MEMBER SERVICES
 Major support functions:
 Training
 Workforce management: process of balancing the service level and cost structure
 Quality management/performance management

 Methods of accessing member services
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Interactive voice response
Inbound telephone calls
Mail/paper-based communications
E-mail
Web-chat/text messaging
Mobile devices – smartphones/tablets

BEHIND THE SCENES

• First contact resolution
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“Completing the transaction in such a way that the member has no reason to contact the plan again with the same issues”

BEHIND THE SCENES
 CTI (computer telephony integration)
 Takes caller information to access customer data bases to identify the member who is trying to contact member services.

 ACD (automated call distributer)
 Device that automatically routes contacts based on program distribution instructions

BEHIND THE SCENES
 IVR Systems
 A form of self service that does not require the intervention of a member services representative

 Benefits:
 Faster data entry
 Increased Accuracy
 Lower Cost

 Other services
 Mail and paper based
 Email Connection
 Web Chat /Text messages
 Internet /Web Self Service

BEHIND THE SCENES
 Understanding the Major Issues
 4 Major Issues:
1.
2.
3.
4.

Claims processing and payment issues
Enrollment and ID cards
Provider accessibility
Benefi t Issues

COMPLAINTS, GRIEVANCES, &
APPEALS
 Resolution of complaints is usually informal, but CSR must document every contact with a member expressing dissatisfaction.
 If complaint alleges quality of care problems, medical director must be notifi ed.

 Grievance - a formal complaint, demanding resolution or a formal response.
 Ex. Formal letter to insurance commissioner charging insurer with deceptive sales and marketing practices.

 Formal Appeal Process
 Employee Retirement Income Security Act (ERISA) – creates specifi c consumer rights to appeal a denial of benefi ts coverage.  ACA further codifi ed those rights

APPEALING HEALTH PLAN
DECISIONS
 Aff ordable Care Act
 Internal Appeal --> External Appeal
 Appeal rights depend on the state you live in and the type of health plan you have. Some group