Adapt to rising member and provider service expectations

Deliver service excellence with the industry’s first single source of truth to manage member and provider self-service and benefit inquiries.

Industry Challenge 

  • Complex process of answering benefit inquiries 
  • Involves multiple manual steps, several data sources, and complex job aids 

Impact 

  • Increased benefit explanation errors 
  • Stretched call handle times 
  • Unsatisfied members and providers 

Our Solution 

  • Leverages Artificial Intelligence (AI) to pull complete and accurate information needed to answer member and provider benefit inquiries 
  • Mitigates errors and inconsistencies 
  • Eliminates reliance on multiple data sources 

Industry Challenge 

  • Answering benefit inquiries is long and complex process 
  • It requires customer service representatives (CSRs) up to 12+ steps and 15+ clicks across 7-11 different systems/sources 

Impact 

  • Inefficient process 
  • Suboptimal member and provider experience 

Our Solution 

  • Leverages AI and Natural Language Processing (NLP) to automate member and provider self-service 
  • Uses AI and NLP to look for a match for service in its library (medical dictionary with 40,000+ terminologies) and displays the correct words or phrases to the CSRs 
  • Fast-tracks the entire process of addressing the incoming inquiries 

Industry Challenge 

  • Some queries are highly complex to answer for most CSRs 
  • Member or provider talks to multiple agents over multiple calls to get an accurate and complete answer 

Impact 

  • Decreased first call resolution rates (FCRs) 
  • Unsatisfied members and providers 

Our Solution 

  • Enables CSRs to easily search and access information related to any technical query of providers and members 
  • Improves FCRs 

Industry Challenge 

  • Dependency on multiple data sources and manual processes 
  • Lack of highly trained CSRs (due to 30% industry attrition rate)  

Impact 

  • Increased number of steps and call time to answer benefit inquiries 
  • Suboptimal customer experience 
  • Increased call handle time 
  • Increased dead air during calls 

Our Solution 

  • Leverages AI to learn from each interaction 
  • Delivers increasingly smart suggestions to CSRs for answering queries 
  • Utilizes NLP to record the discussion between CSR and member/provider 
  • Stores the recorded discussion in the form of a .pdf file and stores it for future reference 
  • Reduces call handle time 

Industry Challenge 

  • Low FCR 
  • Stretched call handle times 
  • Frequent benefit explanation errors 

Impact 

  • Negative impact on members’ and providers’ experiences 
  • Decreased Star ratings 

Our Solution 

  • Ensures that customer inquiries are accurately, completely, and timely addressed 
  • Improves member and provider network’s satisfaction level 
  • Improves Star ratings 

Frequently Asked Questions (FAQs)

Here are the most frequently asked questions about implementing end-to-end benefit plan management solution and partnering with Simplify Healthcare.

1. What is member and provider benefit inquiry management?



Most Health Plans, TPAs, and ASOs face challenges with manual and inaccurate explanation tools to improve self-service and handle benefit inquiries, version control issues, redundant and disconnected benefit content across the enterprise, and extended call handle times. Member and provider benefit inquiry management is the process to support health plans by automating end-to-end customer service management and deliver accurate and complete information to your call center and self-service portals.

2. What are the challenges with traditional customer service management processes?



Traditional customer service management for Payers, TPAs, and ASOs are manual and prone to errors. Customer service users are frustrated over the amount of time and steps required to accurately quote benefits leading to many errors and overall reduced member and Provider satisfaction. The challenge:

  • Current benefit explanation tools are incapable of providing accurate member or provider self-service.
  • The process of searching through benefit data sources-marketing and other documents are time-consuming and error-prone.
  • Benefit explanations are not human-friendly with multiple versions and inconsistency across the enterprise.
  • Several manual steps, several data sources and following of complex job aids increase errors and result in MTM and NPS impacts.
  • With inconsistent data customer service team may need to spend extended time to
    research and respond to benefit inquiries and reduced first call resolution rate and extended call handle time.

3. Why use a client setup and management solution?



Here are some of the key benefits of automating your customer service management processes:

  • Create a single source of truth for your benefit explanation data to provide fast and accurate benefits answers consistently across all your channels.
  • Automate workflows for easy collaboration across all stakeholders, reduce administrative costs, and increase member retention and service search capabilities using English text or codes.
  • Reduce errors, call handle time, and inconsistency across channels.
  • Increase first call resolution rates.
  • Reduce the amount of time and steps required to accurately address benefit inquiries.
  • Automate members and providers self-service and increase satisfaction.
  • Improve Star ratings.

4. How can eServiceSync™ help you automate processes using a single source of truth?



eServiceSync™ enables Healthcare Payers and TPAs, and ASOs to provide better member and provider self-service by enhancing their customer service capabilities with an end-to-end automated platform that integrates into your existing CRM investments. The proven platform helps create a single source of truth to deliver accurate and complete information to your call center and self-service portals, improve call handle times and first call resolution rates, provide current, accurate, and complete benefit explanations, and improve your member and Provider experience, and increase your STAR ratings.

Payers and TPAs can now automate workflows for easy collaboration across all stakeholders, reduce administrative costs, and increase member retention and service search capabilities using English text or codes.