Handle Complaints with grace and empathy
Not every call or email is with a happy member. When a member reaches out with a grievance, it needs to be dealt with quickly and appropriately. Everise has extensive processes in place for recording and responding to grievances. When a member makes a customer service complaint, the agent will respond based on the protocols for each client, determining its type (complaint, grievance, appeal request) and working to solve it when possible. When that is not possible, we will follow the client’s procedures for processing.
In support of handling grievances, Everise has created an internal grievance team that is fully versed in all the grievance and appeals regulations. The team reviews each call and associated documentation to determine if the complaint was managed appropriately according to both the client protocols as well as associated regulatory requirements. When needed, they provide feedback to the agent that handled the complaint and determine if any additional action is needed. Along with the member complaint function, the team also has a sales investigation unit in place to open formal investigations into any sales allegations.
Medical Record Retrieval
There are many instances when a member’s medical chart is needed by a health plan. This could be as reference material to an appeals request, used to determine Risk Adjustment, or in supporting care management activities to ensure appropriate care is made available to a member. While medical records legally must be made available from a provider when necessary, the actual retrieval process may not be simple. Everise is well-versed in myriad ways to securely acquire medical records and other confidential information. This can include outbound requests to a provider (phone or email), secure receipt of FAX or electronic forms, and coordinating with local resources that can physically visit a provider’s office and acquire a paper copy of the record.
Positively Impact Your Stars Rating
For 2023, CMS changed the formula for Star Ratings, doubling the impact of CAHPS survey results, patient experience, and complaints measures. This essentially quadruples the impact of member experience on a plan’s overall Star rating. While in the past, plans have concentrated on maximizing performance on clinical quality (e.g., HEDIS and Part D) and operational measures, this is no longer enough.
Everise is the BPO expert in ideal member experience. Our focus with every payer program is to ensure the member experience is as high quality as possible thereby helping to improve the member experience measures. A key component of the Everise operational model is to proactively recommend modifications to each client program, leveraging proven techniques that help improve the member experience. All of this is done with the goal in mind of positively impacting each client’s Star rating.
There are times when a health insurance company needs a partner to step in a provide additional manpower to help solve an immediate crisis. This could be dealing with an unexpected influx of member requests, a change in a plan or significant changes in a provider network that requires proactive notification of the member base, or activities surrounding plan mergers. With our business model designed to rapidly staff client engagements, Everise can quickly ramp up a temporary workforce to assist with these challenging situations.