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Health plans face significant challenges in complaints management, with unresolved member issues leading to increased churn, lower Star ratings, and strained enrollment and retention efforts. Member complaints arise at various touchpoints in the healthcare journey–ranging from enrollment issues to claims delays, denials, and unsatisfactory settlements–each requiring precise resolution to mitigate risks and maintain compliance.
Backed by decades of expertise, the ResultsCX Complaints Management Program equips health plans to proactively address member concerns and reduce churn. By integrating dedicated complaint management teams with automated workflows and advanced analytics, we identify and resolve issues at an early stage, transforming friction points into opportunities for building loyalty and driving growth.
According to the National Association of Insurance Commissioners (NAIC), the top three causes of member complaints are claim handling delays, unsatisfactory settlements, and claim denials. Through comprehensive analysis of complaints data, we detect changing buying patterns and early signs of disenrollment to pinpoint members at risk of churning. These insights enable our frontline teams to engage meaningfully with members and proactively implement targeted interventions to drive retention and long-term success.
Proactive identification of potential issues reduces the load on service teams
Hyper personalized and effective resolution improves the member experience
Improved member satisfaction and Star ratings lead to increased retention and growth
While individual issues may seem minor, multiple issues can add up quickly, reaching a tipping point and driving member disenrollment. Our expert complaints taskforce utilizes 7QC tools and complaint call insights to analyze root causes and trends. This allows us to provide targeted recommendations that enhance First Call Resolution (FCR) and Customer Satisfaction (CSAT), while also enabling proactive outreach to address recurring issues throughout the customer journey.
Leverages advanced interaction analytics tools to analyze call data and detect trends before complaints arise, preemptively uncovering potential causes of complaints.
Harnesses predictive data to drive proactive outreach and intervention, addressing member concerns before they escalate to the CMS’s Complaints Tracking Module (CTM).
Engages members– across channels–based on a point-based system that highlights the seriousness of complaint, enabling proactive risk management for issues like benefit changes.
Experienced advocates skilled in complaint resolution and plan advisement use advanced tools to manage member interactions and ensure smooth program launches. Dynamic coaching strengthens follow-ups and processes for higher FCR and improved CSAT.
Drives operational excellence through accuracy, Root Cause Analysis (RCA), and timeliness–while powering continuous process improvements with actionable insights into people, processes, and systems.
By seamlessly blending advanced technology with human expertise, our complaint resolution framework delivers better outcomes–all while preserving the element of empathy essential to successful complaint resolution. We optimize complaint handling through smart classification, triaging, and automated routing, ensuring most cases are resolved at the first point of contact or assigned accurately to either early resolution or specialist teams. Automated business rules evolve continuously to enhance speed, accuracy, and efficiency, ensuring a seamless, customer-focused complaint resolution experience.
Our tech-driven RCA workflow transforms complaints into powerful insights, driving meaningful improvements in products, services, and processes.
An automated workflow aggregates data from call transcripts, CRM, email, chat, and complaint systems, ensuring a comprehensive, real-time view of the customer journey.
Using Natural Language Processing (NLP), our RCA engine pinpoints complaint drivers and links them to key external factors such as product specs, pricing changes, sales processes, and contact center performance.
Deep insights fuel tangible improvements—whether it’s updating product literature, enhancing training for relationship managers, or refining underwriting checks to prevent recurring issues.
Visual dashboards deliver findings, outlining complaint trends, root causes, and strategic action points to drive long-term improvements.
By blending targeted coaching with rigorous governance, our Complaints Management Program equips healthcare advocates with the skills and insights needed to effectively resolve member concerns, in turn boosting member experience and loyalty.
Advocates are trained to navigate complex complaint scenarios, ensuring effective resolution and provider education.
Given the intricacies of plan structures, our team helps health plans communicate plan details more effectively to members.
The CMT team identifies patterns of dissatisfaction, uncovering underlying issues, guiding plans toward optimal solutions.
Experienced agents leverage leading-edge tools to manage complaints efficiently and close the loop on member interactions.
Frontline agents receive targeted coaching on action items like member callbacks, driving process improvements and ensuring speedy resolution.
With over three decades of complaint management experience, ResultsCX is your trusted partner in designing a seamless and effective complaint handling process. Our flexible resourcing ensures that your operations are equipped to handle varying demands, while our outcome-driven reporting provides clear insights to measure success.
We have been recognized a leader across most aspects of our work – from Customer Experience Management (CXM) to security to workplace innovation. We believe that every day brings new opportunities to do better and become better. See what industry analysts and customers are saying about ResultsCX
