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Reduce the Volume of Calls, Appeals, and Grievances by Improving EOBs and Forms

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

Are you tired of the endless stream of calls flooding your call center, the constant barrage of appeals, and the frustrations of members with their healthcare claims? You’re not alone.  

In this article, we’ll explore how to tackle these challenges head-on with the use of leading forms automation and customer communications management solutions, leading to a smoother experience for both you and your members. 

Why Your Members Find Communications Difficult to Comprehend 

You’ve probably noticed that your members often struggle to comprehend how their claims are paid or what their responsibilities entail. Research from the Kaiser Family Foundation (KFF) highlights this issue, showing a clear gap in understanding among healthcare consumers. Additionally, new regulations like the No Surprises Act and CMS price transparency mandates further emphasize the need for clarity in healthcare communications. While there has been significant progress over the last few decades, health payers still fall short in providing communications in plain language that are both clear and jargon-free.  

Ultimately, this leads to a pressure cooker of confusion, stress, and unnecessary burden on both members and staff. In this collision of two forces—the lack of clarity and a lack of health literacy—the negative impact continues to grow. Some of these impacts include: 

  • Increased appeals, including those won by the member
  • Poor member loyalty and retention rates (more on that later) 
  • Over-burdened call center staff due to high call volumes 

Member Loyalty and Retention Are Struggling

The landscape of healthcare is evolving, and with it, so are your challenges. Customer loyalty and retention are at stake, as evidenced by data from the Forrester CX Index. With over 43 Medicare Advantage plans to choose from, the competition adds more weight to the retention imperative facing health payers. High administration costs and increased churn rates are putting pressure on profitability.  

However, there’s hope in the form of AI/ML technologies and advanced data visualization tools, which have the potential to revolutionize the way you communicate with your members. As I stated above, poor member loyalty is just one of the negative impacts of poor communication. Without the necessary transparency and clarity, it’s difficult for members to trust your organization. According to a J.D. Power survey, trust is a factor most highly correlated with Medicare Advantage plan renewals.  

Source: INNOVATE 2024, Internal research by Smart Communications 

Cloud-based CCM Software: A Modern Solution for Modern Problems

Your mindset and legacy toolset may be holding you back from embracing these transformative technologies. By failing to link operational metrics to customer experience and business outcomes, you’re missing out on valuable opportunities for improvement. The breakthrough lies in leveraging AI/ML to enhance readability and interactive charting to improve data presentation, ultimately leading to greater transparency and understanding. 

Smart Communications understands the challenges you’re facing and is uniquely positioned with the strategies and solutions to address them. We specialize in customer engagement and know how to leverage AI/ML and data visualization to improve customer comprehension and experience. By keeping you compliant with regulatory requirements while introducing CX enhancements, we can help you save costs, improve loyalty, and ultimately, drive profitability. 

If you’re tasked with reducing call volume or appeals, or improving member retention, our solutions offer a clear path forward. By enhancing the readability and comprehension of key communications and providing self-service options, you can streamline processes, build trust, and transition members to more profitable plans. 

Conclusion 

We back up our claims with statistics, analyst accolades, customer testimonials, and recent wins with industry leaders. Our ROI calculator shows the tangible benefits of action, mitigating social and opportunity risks.  

By embracing innovative technologies and reimagining your approach to member communications, you can overcome the challenges of high call volumes, appeals, and grievances. With our expertise and tailored solutions, you’ll not only save costs and improve efficiency but also enhance member satisfaction and loyalty. 

Ready to take the next step? Learn more about our Connected Claims platform or see a demo of our SmartIQ™ and SmartCOMM™ solutions in action. Contact us today to start streamlining your healthcare communications and reducing calls, appeals, and grievances.

Enhancing Healthcare Outcomes with Health Risk Assessments

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

According to a recent Commonwealth Fund study of Organisation for Economic Co-operation and Development (OECD) data, healthcare in the United States is more expensive than anywhere else in the developed world, yet health outcomes are among the worst. Chronic health conditions play an outsized role on both sides of that equation. 

The Centers for Disease Control and Prevention (CDC) attributes an astounding 90% of the nation’s annual healthcare expenditures to people with chronic and mental health conditions. The OECD data showed that 30.4% of adult Americans have multiple chronic health conditions. A different study estimated that the number of Americans aged 50 or older with at least one chronic disease was 137.25 million (nearly one-third of the total U.S. population) and that number will nearly double by 2050. 

The OECD data put the per-person U.S. healthcare costs at nearly $12,000 (and rising), nearly twice as much as the other 12 developed countries in the dataset. While several factors contribute to this financial burden – ranging from inpatient and outpatient hospital visits to prescription drugs and preventative care – administration costs in the US stand out, being four times higher than those in comparable nations, as reported by the Peterson-KFF Health System Tracker. A second Commonwealth Fund study found that administrative expenses contribute 30% to the higher costs Americans pay versus other developed nations. 

In combating these challenges, one tool emerges as a beacon of hope – Health Risk Assessments (HRAs). When utilized and efficiently administered, HRAs can help lower your healthcare administration costs, increase patient engagement, and improve health outcomes: 

What Is a Health Risk Assessment?

 AN HRA encompasses a comprehensive questionnaire covering a wide range of health topics: 

  • Self-reported health status: Patients are asked to rate their overall health and well-being. This can provide pointers to potential health issues. 

  • Personal health history: This includes past illnesses, surgeries, and hospitalizations. 

  • Family medical history: Identifies potential genetic predisposition to certain conditions. 

  • Chronic disease assessment: Identifies whether and how a patient is managing various conditions, including diabetes and cardiovascular conditions. 

  • Medication review: Listing prescriptions, over-the-counter drugs, and supplements can help physicians spot drug allergies, interactions, and adherence. 

  • Immunization status: Ensures that patients are up to date with recommended vaccinations.  

  • Behavioral risks: Identifies lifestyle factors like smoking, alcohol consumption, and substance abuse impacting health. 

  • Nutritional assessment: Evaluates the patient’s nutritional status, dietary habits, and weight management to help identify malnutrition or obesity. 

  • Functional assessment: Evaluates the activities of daily living (ADLs) and independence.  

  • Depression screening: Identifies individuals at risk for mood disorders, including depression. 

  • Fall risk evaluation: Assesses mobility, balance, and fall history.  

  • Social Determinants of Health (SDoH): Identifies how social factors such as housing stability, access to transportation, and social support systems affect a patient’s health. 

Why Use a Health Risk Assessment? 

HRAs have proven to improve health outcomes and lower healthcare expenses. The assessment guides the provider in creating a long-term, personalized care plan for the patient and making recommendations to improve the health of the patient. By proactively managing health, patients spend less money compared with reactively treating unmanaged conditions. 

Despite the mandated use by the Centers for Medicare and Medicaid Services (CMS) with requirements for completion within 90 days of enrollment and annually thereafter, low completion rates persist among health plan members.  

One reason for the lack of patient engagement could be the prevalent use of paper or inflexible HTML forms for HRA collection.  

How to Increase HRA Completion Rates 

Modern patients expect convenient, effortless experiences, particularly those with limited.  or impaired cognitive or motor abilities. Using paper or even fillable PDF forms is not the way to go. 

Electronic HRAs are specifically permitted by CMS. The Affordable Care Act (section 4103(b)) Element 4 states that the HRA “may be provided through other means appropriate to maximize accessibility and ease of use by beneficiaries, while ensuring the privacy of beneficiaries.” Which is why the CDC says that web based HRAs are the preferred modality for HRA administration. 

Yet, from what our customers tell us, many of the electronic health risk assessment tools are difficult to manage. This makes implementing an HRA, particularly one that conforms to CDC recommendations, difficult at best. 

Introducing SmartIQ™ for Health Risk Assessments 

SmartIQ makes creating and updating the health risk assessment questionnaire a breeze, ensuring compliance with CMS and CDC guidelines for digital administration.  Features include:  

  • Compliance with Section 508 accessibility standards 

  • Secure hosting on a HIPAA-compliant SaaS platform 

  • Pulls in known patient data for review and revision 

  • Compatibility across devices for convenience.  

  • User-friendly interface for practitioners or staff 

  • Seamless integration with CAPS, EMR, and PHR systems 

Ready to increase your health risk assessment completion rate? Click here to learn more about SmartIQ. 

How to Improve Patient Communications and Experiences: Applying Lessons from the Past to Achieve Future Success

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

The concept of “patient experience” has evolved over time, and its definition has been refined by various organizations. Let’s delve into its history: 

1. What Was Patient Experience Like in the 1990s?

During the 1990s, understanding patient experience gained prominence to assess the quality of care provided. However, at that time, there were no established attributes defining what contributed to a patient’s experience. 

In 1995, the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program was created in the United States. It aimed to survey patients about their experiences, focusing on aspects that mattered to them rather than mere satisfaction. The CAHPS and HCAHPS surveys did not ask patients about their satisfaction; instead, they sought insights into critical aspects of their experiences. 

2. Attributes of a Good Patient Experience

The Agency for Healthcare Research and Quality (AHRQ) defines patient experiences as “aspects of healthcare delivery that patients value highly when seeking and receiving care.” These aspects include: 

  • Timely appointments 
  • Easy access to information 
  • Good patient communication 

The National Health Service (NHS) in the United Kingdom further categorized patient experience into eight dimensions: 

  1. Respect for patient values, preferences, and needs 
  2. Coordination and integration of care 
  3. Information, communication, and education 
  4. Physical comfort, including pain management 
  5. Emotional support for clinical fears regarding the patient and their family 
  6. Involvement of family and friends 
  7. Transition and continuity between locations and types of care 
  8. Access to care, including waiting times and time between admission 

So, while patient experience has evolved over time, the focus has been – and remains today – on understanding and enhancing the aspects that matter most to patients during their healthcare journey. Clearly, communication is one of those aspects. 

The Types of Patient Communications

There are several types of patient communications, including: 

Verbal Communication

  • Face-to-Face: Direct conversations between patients and healthcare providers during clinic visits.
  • Phone Calls: Conversations over the phone to discuss medical concerns, appointments, or follow-ups. 
  • Video Calls: Virtual consultations that allow visual interaction. 

Written Communication

  • Emails: Used for non-urgent communication, appointment reminders, or sharing test results. 
  • Letters: Formal written communication for referrals, medical summaries, or follow-up instructions. 
  • Faxes: Still used in some healthcare settings for transmitting documents. 

Electronic Communication

  • Electronic Health Records (EHR): Providers document patient information electronically, facilitating communication across healthcare teams.
  • Patient Portals: Online platforms where patients can access their health records, communicate with providers, and schedule appointments. 

There are also non-clinical patient communications, such as those in the revenue cycle management (RCM) space, including statements and payment/collection correspondence. 

While we’ve seen many technologies introduced to digitize verbal communication, and electronic communication is inherently digital, many written communications are still analog. They may start as digital documents, but they are usually not delivered that way. And email communications are often ad hoc and not centrally managed, exposing providers to compliance risks and human error. 

Digitally Transform Your Patient Experience with Communications

If you’re looking for a solution to help improve your patient experience with written communications, we’ve got one! 

Our SmartCOMM™ solution helps providers manage clinical and non-clinical communications, especially provider-to-patient communications. All SmartCOMM communications start from a centralized repository of templates, which provides consistency of branding and language. The SmartCOMM Draft Editor can be embedded into other solutions, including EHR and RCM systems, giving practitioners and other staff a simple, familiar, word processor-like experience. Communications can be sent via a patient’s preferred channel, whether that’s email, print and mail, or posted to a portal. Plus, all communications and edits are tracked for compliance purposes. 

For more information on how you can improve patient experience with communications, download our data sheet.

Revolutionizing Medicare Member Onboarding: A Strategic Guide for Enhanced CX and Profitability

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

Imagine navigating a complex healthcare system, trying to decipher benefits like a cryptic code. This is the reality for most Medicare Advantage members. Between trying to understand what’s covered, calculating costs, and grasping the nuances of doctors and drugs creates a foggy and frustrating experience. These challenges, naturally, begin at the member onboarding phase of your members’ journey with your company. 

The onboarding materials you send to your new members are more than documents; they’re heavily regulated and almost prescribed by the Center for Medicare and Medicaid Services (CMS). And what’s the typical response? Most payers opt for the minimum to meet regulations. It’s a maze of complexity, but what if there’s a way to unravel it? 

In this article, we’ll untangle the challenges healthcare payers like you are facing and how you can revolutionize the member onboarding process for Medicare Advantage plan enrollees. 

Trends Shaping the Future of Member Onboarding 

The world is evolving, and so are the expectations of healthcare consumers. Data from the Kaiser Family Foundation (KFF) paints a stark picture – members grapple with understanding benefits and costs. It’s not just an inconvenience; it affects customer loyalty and retention, as underscored by Forrester CX Index 2023 data. A bad experience isn’t just a one-time setback; it’s a predictor of customers leaving. 

But here’s the pressing issue – you’re not just dealing with customer satisfaction challenges. You’re facing higher administration costs, driven by soaring call volumes and appeals. The numbers from KFF, showcasing Star-level enrollments and quality bonus payments (QBPs), tell a story of attrition and churn, impacting your revenue. 

Amidst these challenges, there’s a new potential on the horizon – the transformative power of AI/ML and advanced data visualization tools. Picture a scenario where customer communications, like the benefits booklet, become crystal clear, leading to fewer calls to the helpline, decreased appeals, lower costs, reduced churn, increased revenue, and improved profitability. 

However, obstacles lurk in the form of mindset, legacy platforms, and enterprise architecture issues. There’s a new potential, though, in the form of AI and machine learning. These cutting-edge tools will eventually help you enhance document readability and deploy data presentation tools to bring transparency to how claims are paid. 

The Solution: Cloud-based Customer Communications Management Software for Member Onboarding

SmartCOMM™ is a CCM solution poised to help you revolutionize the Medicare member onboarding process at your organization. High administration costs, stemming from call volume and appeals due to member confusion, are a few of the hurdles we specialize in helping healthcare payers overcome. Additionally, one of our biggest goals is to help you change the mindset of your colleagues when it comes to migrating to the cloud, away from clunky and ineffective legacy tools. 

While your competitors, and possibly even your current solution providers, don’t have a clue how to leverage AI/ML and data visualization to improve comprehension or customer experience, we do.  Our sophisticated, cloud CCM solution can do more than help you remain compliant, although that is a prime capability of SmartCOMM. We’ll also help you shine in the eyes of your prospects, current members, and the C-suite. 

Interested in learning how to overcome common objections to being a change agent? Check out: ‘Building a Business Case for Change: How to Secure Stakeholder Buy-In When Purchasing Enterprise Customer Communications Management (CCM) Software’ 

What’s In It For Your Organization?

Now, let’s talk about you – the one tasked with deflecting calls from the call center, reducing appeals and grievances, and improving member retention. Organizational complacency and your members’ past experiences with commercial plans may serve as internal roadblocks to making a change. However, it’s time to recognize that improving member comprehension of member materials, particularly – but not exclusively – during the onboarding phase, is the master key to reaching process improvement goals and converting commercial members into Medicare Advantage enthusiasts. This will require the right strategy and, even more, the right software solutions. 

SmartCOMM has helped health insurers enhance the readability and comprehension of key communications, such as benefits booklets, summaries of benefits and coverage (SBCs), and other plan documents. And here’s the kicker – no other vendor is on this path. We’re pioneers, and we’re inviting you to join us on this transformative journey. 

What Are the Risks in Choosing SmartCOMM for Your Medicare Member Onboarding Strategy? 

In the world of promises, we deal in proofs. Analyst accolades offer the necessary validations of our capabilities, like the recent placement in Quadrant Knowledge Solutions’ SPARK Matrix 2024 Report which named SmartCOMM a “Technology Leader”. In fact, the report went further to describe SmartCOMM as “…the most user-friendly solution for multi-line and multi-brand businesses serving diverse cultural markets.”  

Look at the giants who’ve walked this path before you – Centene, AXA Health, Meritain, Priority Health. Their successes with our products in the senior and government markets can provide you with the assurance that choosing us won’t get you fired.  

Still skeptical? Our ROI calculator can help you see that the cost of doing nothing outweighs the cost of doing something. We can help you clear up member confusion, reduce your call and appeal volumes, and bolster your bottom line. 

Conclusion 

Now that we’ve painted the vision, it’s time for you to take the first step. Learn more about how we can transform your onboarding process. Witness the power of SmartCOMM in action – see how it can elevate the CX and EX of crucial documents like ID cards, provider and pharmacy directories, or drug formularies. 

Don’t let hesitation be your stumbling block. Let’s discuss how our partners can guide you in leveraging SmartCOMM for managing the creation and CMS approvals of vital materials like Annual Notice of Change, Evidence of Coverage, and Summary of Benefits. 

The future of Medicare Advantage success isn’t a distant dream; it starts with your decision today. 

Contact us to discuss how we or one of our partners can help you leverage SmartCOMM for managing the creation and CMS approvals of materials like Annual Notice of Change, Evidence of Coverage, and Summary of Benefits.

4 Reasons to Attend the Banking Automation Summit

Posted on by Scott Draeger

By Scott Draeger, SVP of Product Marketing and Vertical Solutions 

One of the reasons I enjoy working at Smart Communications is because it allows me to learn about, and discuss, the products that help banking leaders around the world improve the way they onboard new clients, better serve their current clients, and stay ahead of regulatory changes in an uncertain economic climate.  

Getting out to learn what’s on the mind of bankers, and the description for the Banking Automation Summit in Nashville, TN seemed like my kind of event. I’ll be there March 18-19th with others from my team at Smart Communcations, and we hope to see you there! In this article, we’ll dig into four reasons to attend the event, but first let’s look at how our software solutions help banks and FSIs provide exceptional customer experiences. 

Digital-First Engagement for Banks 

The event description grabbed us, “Anchored in intelligent automation strategies, this event gathers stars from the financial sector, offering unparalleled insights into the merger of cutting-edge tech and banking. Amidst a relaxed yet professional setting, attendees are poised for genuine, high-quality networking, ensuring they engage, learn, and collaborate.”   

Smart Communications has helped financial services organizations like yours deliver better conversations with your customers using our market-leading customer communications management technology. We help drive digital-first engagement across banking, credit, and asset management applications. Our SmartCOMM™ and SmartIQ offerings help banks save millions with account opening, onboarding, and client servicing conversations made faster and simpler.  

1. Learn from Banking Leaders in Transformational Roles 

As the Smart Communications team prepares for the summit, we’re building out our schedules just like you. The team is looking forward to presentations from a variety of speakers with a wide range of perspectives from their specialties. We are looking forward to Anuj Shah from PNC’s AI perspective, Dominic Cugini from Key Bank for a Chief Transformation Officer’s view, Jude Schramm from Fifth Third for the CIO’s frame of reference, and Maria Mason from Citizens Bank for an Enterprise Product Manager’s outlook. 

2. Align Your Challenges to Customer Feedback

While we are certainly interested in learning at the event, we have a lot to offer as well. On your way to the conference, check out our 2023 Benchmark Report for the Financial Services Industry. The three key findings show that customer communications are a strong driver of loyalty, generational channel preferences should not be dismissed, and consumers perceive ease of interaction as trust from their banks. 

3. Level Up Your Professional Network

While you are at the Banking Automation Summit, make sure to meet with some of our team members. We can show you how our customers are staying ahead of regulations while exceeding customer expectations. We will show you how our cloud-native Customer Communications Management (CCM) and forms automation technology is instantly deployed, quickly implemented, and in line with your bank’s 2024 goals.  

As you think about collaborating with peers at the Banking Automation Summit, it is important to seek out people from other banks with different roles. At Smart Communications, we find the greatest successes start with larger teams. As you look at the customer experiences that are associated with communications, you will find people that focus on challenges at the customer-facing front office, integrations of the middle office, and regulatory constraints of the back office.  

4. Tap into an Amazing Source of Peer Insights

If you want to engage, learn, and collaborate, think about some small talk you could make with the people at the summit. Ask some of the speakers and other attendees about their roles, and how they approach communication and customer experience. Chat with some of the attendees over a snack break what they could automate if rates go up three percent.  

At the cocktail reception, see what projects others would accelerate if rates decreased by three percentage points. While you are waiting for the session to begin, see if your neighbor turns regulations into communications quickly? Ask how they track the history of the conversations that make up each customer’s relationship with your bank. 

Connect with the Smart Communications Team

We’ll be in the sessions, learning with you. Connect with us at the summit. If you can’t wait until then, take a look at our Loan Application Demo, Loan Servicing Demo, or book a demonstration before the event. We’re excited to see the sessions, watch the keynotes, and meet people like you at the Bank Automation Summit. See you in Nashville! 

How to Improve Patient Experience with Forms

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

Patients are sick…of tedious, cumbersome forms. They’re everywhere in healthcare and they provide bad patient experiences. Most repeatedly ask for the same information, the majority are long or otherwise complex, and many need to be printed out and signed by hand. Signing sounds simple, until you consider those patients that have a hand injury, are arthritic, or are otherwise unable to put pen to paper. 

I’ll say it: Your forms are evidence of a complete lack of empathy for patients. 

First Things First: Acknowledge the Burden You Place on Patients During Intake

Technically, the process of finding then scheduling care provides the first impression. In most cases, that happens over the phone or online, so it feels separate. Intake (or admissions) is usually done onsite, in person, and on the day of the appointment and it’s full of paper forms, including: 

  • A patient demographic information sheet 
  • An informed consent form 
  • Authorizations and assignments (e.g., patient responsibility for payment) 
  • Appointment of a personal representative form 
  • Coordination of benefit forms 
  • HIPAA authorization to release information 

That’s already a lot of forms, and the list doesn’t include patient-, provider-, or procedure-specific forms like a new patient health history or screening tools like abuse or social determinants of health. 

Often, these forms are individual documents that are manually selected and collated by staff, which means it’s easy to miss one. And because they’re created as individual forms, they each require a patient signature. My hand cramps just thinking about the intake process! 

Next Steps: Understand Where the Issues Arise with Your Form Processes

Many of the same forms need to be completed for each patient visit. For example, Medicare-eligible patients are supposed to complete a Medicare Secondary Payer questionnaire every time services are rendered. This often means the patient is handed a fresh set of blank forms that must be filled out from scratch. This compounds the frustration and anxiety patients feel and reinforces a bad patient experience. 

Studies from the Centers for Medicare and Medicaid Services (CMS), The Department of Health and Human Services (HHS), and the Kaiser Family Foundation (KFF), as well as our own research, show that patients expect known information to be pre-populated on forms. Patients prefer to be able to review and revise information rather than reenter it. This is rarely the case with healthcare forms. 

There Is a Solution: Digitally Transform Your Patient Experience with Forms

Thankfully, there is a better way. 

Our SmartIQ™ software makes it easy to transform your patient forms into guided digital experiences. These experiences can be embedded in patient portals and apps and branded to match. SmartIQ can integrate with your EHR, RCM and other back-office systems to pull in known patient data so that patients and staff don’t need to rekey information. Information can be entered once and automatically applied to multiple forms. Patients can attach required documents like insurance cards, medication lists, and advance directives with the click of a button from the comfort of their home (where they likely keep this information).  

Forms can be started at home on one device, including mobile phones and tablets, and completed in your office on another. And SmartIQ integrates with popular digital signature solutions so that multiple forms can be signed at once. Then, the completed forms can be sent either as data or documents to your applications or document repository. 

For more information on how you can improve patient experience with forms, download our white paper.

What the CMS Prior Authorization Rule Means for Healthcare Payers

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications

It took a little longer than I expected, but on January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) issued its final rule regarding data interoperability and prior authorizations (PAs).  

In this article, I address some of the most frequently asked questions about the final rule, and what I see as key takeaways for health payers. Plus, learn how leading customer communications management (CCM) solutions can help you comply with new, and existing, regulations. 

Past Is Prologue for the CMS Prior Authorization Rule

In December of 2022, CMS issued a proposed rule, “that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services.” 

To improve access to health information, CMS proposed payers adopt Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standards and publish new or updated patient and provider application programming interfaces (APIs). The proposed rule also outlined an electronic prior authorization process that would require payers to determine and communicate a decision within 72 hours (expedited PAs) or seven calendar days (standard PAs) and include a specific reason with any denial. 

It took CMS just over one year to release the final rule. I’m sure that the lag was due in no small part to the large volume of correspondence they received about the proposed rule. CMS had to parse nearly 900 letters “with hundreds of individual comments specific to the importance of the topic of prior authorization and the critical timing of addressing this issue.” 

Who Is Affected by the CMS Prior Authorization Final Rule? 

Many US health payers and plans (and a few types of providers) are subject to the final rule, including: 

  • Medicare Advantage Organizations (MAOs)
  • Medicaid managed care plans
  • Children’s Health Insurance Program (CHIP) fee-for-service plans
  • Qualified Health Plan (QHP) Issuers on the Federally-facilitated Exchanges (FFE) 

What Are the CMS Prior Authorization Final Rule Compliance Deadlines? 

Most of the implementation deadlines are January 1, 2027, including the Patient Access API, Provider Access API, Payer-to-Payer API. However, beginning January 1, 2026 (or plan years beginning on or after that date for QHP issuers on the FFEs), impacted payers will be required to annually report “certain metrics about patient access requests made via the Patient Access API.” These metrics include: 

  • The number of prior authorizations requested by type (expedited/standard);
  • The average time between submission and decision; and
  • ​​​​​​​The percentage of prior authorizations approved, denied, and approved after appeal. 

Which Prior Authorizations Are Impacted by the Final Rule? 

Prior authorizations for things like medical services and equipment are subject to the final rule. Prior authorizations for medications are specifically carved out of the final rule. CMS didn’t provide a reason (that I could find) for specifically excluding things like specialty pharmacy prior auths. 

What Is the ‘Plain Language’ Requirement in the Final Rule? 

CMS has mandated that payers communicate several things in “plain language”, including: 

  • The reason for denying a prior authorization
  • ​​​​​​​The benefits to patients of API data exchange with their providers 
  • The benefits of Payer-to-Payer API data exchange 
  • The ability for patients to opt in or out of certain data exchanges and how to do it
  • Explaining the process for requesting patient data using the Provider Access API 

CMS encourages impacted payers to follow the Federal Government’s plain language guidelines available at the plainlanguage.gov website. CMS “did not propose standardized denial codes or a specific set of denial reasons for payers to use.” Instead, they referred to the X12 Service Review Decision Reason Codes, which I find interesting for a few reasons. 

For one, even though they’ve been in use for a long time, I wouldn’t consider the X12 codes to meet the “plain language” test. And throughout the final rule document, CMS appears to be leaning away from X12 in favor of FHIR. For example, CMS refers to the HL7 FHIR Da Vinci Prior Authorization Support (PAS) implementation guide, which maps between FHIR and X12 transactions. Talk about emerging standards: As of this writing, that standard is in the trial use stage. I’m willing to bet it will be finalized relatively quickly, though, given the final rule deadlines. 

What Else Is Included in the Prior Authorization Final Rule? 

Quite a bit, considering it’s over 700 pages! I’ve expanded on some highlights below. 

Impacted payers must establish and maintain a process that allows patients to opt out of data exchange via the Provider Access API, including allowing patients to change their permissions at any time. If there’s one thing providers have proven they’re not good at, it is preference management, so this will be a challenge. 

Impacted payers are required to provide “educational resources in plain language” to patients about the Provider Access API. This must include: 

  • Information about the benefits of API data exchange with provider
  • The patients’ opt out rights
  • Instructions for both opting out of data exchange and for subsequently opting in 

“Impacted payers must make this information available to patients before the first date on which the payer makes their information available via the Provider Access API, no later than one week after the start of coverage, and at least annually. These resources must also be available in an easily accessible location on payers’ public websites.”  

Furthermore, “impacted payers must provide on their website and through other appropriate provider communications, information in plain language explaining the process for requesting patient data using the Provider Access API. The resources must include information about how to use the payers’ attribution process to associate patients with their providers.” 

Payers will need to be able to provide prior authorization information, including “related administrative and clinical documentation”, “while the prior authorization is active and for one year after the last status change”. Payers will also be required to maintain five years’ worth of prior authorization history. 

For additional information, you might want to check out the overview presentation from CMS. 

How Can Smart Communications Help Payers Comply with the CMS Prior Authorization Final Rule? 

There are a few ways Smart Communications can help you meet the requirements of the CMS final rule. 

First, we can help you meet the communication-related requirements, particularly the explanatory and educational communications that will need to be sent to patients, providers and members. SmartCOMM™ would be a great choice for this use case. It’s perfect for high-volume communications like these and it has content analysis tools built in to make sure you’re using plain language. And, with our large and growing list of prebuilt integrations, you can connect it to your enterprise architecture to generate and send communications on demand over the member’s preferred channel. 

If your current prior authorization solutions won’t be enough to handle some of the new requirements, particularly when PAs can’t be auto approved and you need something to manage the back-and-forth between provider and payer, then our SmartIQ™ software might be able to help. It’s particularly good at managing workflows and tracking the metrics you’ll need to start reporting in 2026. 

If you’d like to know more about how we and our partners can help meet the new prior authorization requirements, get in touch with us. We’re here for you.

Unpacking Forrester’s 5 CX Predictions for 2024 and Their Implications for Healthcare Payers

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications

Forrester Research analysts Judy Weader, Christina McAllister, Su Doyle, and Senem Biyikli recently hosted a webinar where they presented their five customer experience (CX) predictions for 2024. As I watched, I couldn’t help but think about the degree to which each applies to healthcare. I won’t give away too much, as you should really watch the webinar and download the related presentation to get Forrester’s full perspectives. But below, I’ll go through each headline and offer some color commentary. 

Prediction 1: Global Average CX Will Improve for the First Time in Three Years

Well, that would be nice. If you’ve been following Forrester’s CX Index reports, you know that healthcare has one of the lowest industry average scores. In the webinar, Weader made the point that the trendline for CX says we’re due to see improvements. For healthcare, we’re long overdue. Weader also noted that Forrester expects APAC and EMEA to make outsized gains in CX. I would have to agree when it comes to healthcare. From my experience, payers and providers outside of North America are further up the CX maturity curve, on balance. 

Prediction 2: 50% of Large Global Firms Will Experiment with Customer-Facing Generative AI

That might be high for healthcare. For the most part, the firms I’ve spoken with are very reluctant to put generative AI (GenAI) out front. Only those that are playing with their own large language models (LLMs) or a hybrid public/private model are thinking of being that bold. Most are looking to use GenAI for creating initial drafts, suggesting edits to existing content, or for first-pass language translation. That’s all behind the firewall. The recent negative headlines about how some payers have been using AI will only slow the adoption of GenAI in healthcare. 

Prediction 3: 50% of Large Global Firms Will Report CX Metrics; Only 5% Will Link to Financials

Both are probably high for healthcare. I’ve only seen a handful of firms publicly disclose their CX metrics. That’s partly because only a few have good metrics to report, but mostly because their CX practices are relatively immature. I have only seen one payer sophisticated enough to link CX through operations to their income statement. I’m sure there are others; the point is, they’re rare. 

Prediction 4: One-Third of Brands Will Launch Experiences That Are Biased, Inaccessible or Harmful

Here’s where healthcare might shine. That’s because we’ve been subject to accessibility regulations for decades. That created a certain disposition towards empathy and formalized processes and procedures. I’ve seen user experience (UX) and CX teams with their own accessibility manuals and style guides. I’ll be very surprised if a single healthcare organization shows up on the offender list. 

Prediction 5: Two out of Five CX Teams Will Turn Away Work Because Their Remit Exceeds Resources

This one is a mixed bag for healthcare organizations. I doubt their CX teams will be flooded with requests; however, I’m sure they are under-resourced. It is a rare payer or provider that fully funds a CX team. That has more to do with company culture than cost structure. The customer just isn’t at the center of many healthcare organizations in the way you’d hope they would be. 

How to Link Forms and Communications to CX and Financial Metrics

I applaud the Forrester analysts for putting these predictions – and themselves – out there. I know they’re basing these prognostications on the past year’s inquiries and briefings they’ve been involved in, so they’re well founded. The one I think that matters most to healthcare payers is the inability to demonstrate the link between CX metrics and business outcomes. 

CX impacts the bottom lines of healthcare organizations. Period. And yes, it is possible to connect CX improvements to financial outcomes. In an upcoming webinar with Judy Weader, I’ll show you:

  • Examples of how forms drive call volume;
  • How communications are linked to appeals; and 
  • Ways to improve CX and business metrics tied to forms and communications. 

If you’re ready to discover how to accelerate the healthcare customer experience at your organization, click the link to register for the webinar: Register Now! 

Revolutionizing Medicare Member Engagement: A Guide to Seamless Advantage Enrollment

Posted on by John Zimmerer

By John Zimmerer, VP of Healthcare Marketing at Smart Communications 

Navigating the world of senior market member engagement poses unique challenges for healthcare payers. As you strive to enhance member satisfaction and enrollment processes, it’s crucial that you address the rising complexities within the Medicare Advantage landscape.  

This blog will shed light on key challenges and provide insights into revolutionizing member engagement for a seamless enrollment process. 

The Challenge of Medicare Member Engagement 

Let’s delve into the pressing issues and explore how a strategic approach can transform the member engagement experience.  

Increased Competition 

Picture this: in the 2023 plan year, the average Medicare beneficiary found themselves amidst a sea of choices, with over 40 plans to sift through, as per CMS data reported by KFF. This staggering number reflects a doubling of available plans over just five years. As a healthcare payer, the challenge lies not only in offering competitive plans but also in ensuring that your members can navigate this abundance with ease. 

Poor Customer Experience 

Adding to the complexity, the US Health Insurers Customer Experience Index Rankings for 2023, presented by Forrester, highlighted a persistent issue. The average health insurer’s customer experience (CX) remained stagnant, placing them at the lower end of the ranking. What’s more, Forrester’s findings revealed that the CX of commercial plans tend to trail behind that of government plans. 

The Influence of Star Ratings 

Amidst the challenges mentioned above, the influence of customer experience on Star Ratings has undergone a significant shift. CX measures currently constitute a substantial 57% of a plan’s Rating. This evolution is pivotal because Star Ratings, as numerous studies affirm, play a decisive role in driving enrollment. As healthcare payers, the question that beckons is clear: In the evolving Medicare landscape, are you positioned to retain or lose members as they transition into this critical phase of healthcare decision-making? Keep reading for strategies to not only meet these challenges head-on but also to redefine the Medicare member engagement experience at your organization. 

Trends Driving the Need for Better Medicare Member Engagement 

According to internal and external research, we’ve highlighted the key trends that will have an impact on Medicare member engagement for the 2024 plan year and beyond. 

1. CX Will Continue to Make a Big Impact to Member Enrollment 

For decades, Forrester has researched the realm of customer experience, consistently revealing its profound impact on customer loyalty and retention. Our latest Healthcare benchmark report aligns with Forrester’s insights, emphasizing that simply one negative experience can drive customers away. Given the weight Star Ratings places on CX, this trend should be top of mind as you plan how you’ll prioritize enhancement to your customer. 

2. Technology Will Play a Pivotal Role in Attracting and Retaining Members 

While commercial plan members may find themselves with limited choices, the scenario shifts when it comes to Medicare Advantage, Medicare Supplement, or prescription (Part D) plans. KFF’s data underscores that merely 18% of Medicare Advantage enrollees are in employer- or union-sponsored plans. Now, consider this: Most Medicare Advantage enrollees (88-94%) rarely switch plans voluntarily. It’s a one-shot opportunity for you as a healthcare insurer to secure a new Medicare Advantage enrollee.  

The potential lies in leveraging data, artificial intelligence (AI), research, and technology to guide existing commercial members seamlessly into the “right” Medicare Advantage plan for them – and crucially, to retain them. Even if you haven’t delivered optimal CX to your commercial members, offering them a seamless Medicare enrollment process—like the one made possible by SmartCOMM™ and SmartIQ™—can alter their perception of your company for the better. 

3. Seamless Processes Will Make or Break Your Medicare Member Engagement Strategy 

Let’s dive into the numbers. An analysis of CMS data by KFF unveils a revealing insight. One-third of Medicare beneficiaries reported finding it challenging to compare plan options. This underscores the key role you play as a healthcare payer. By enhancing the enrollment experience, you’re not just facilitating a process; you’re transforming perceptions and cementing lasting connections with your members. The evolving landscape demands more than traditional approaches; it calls for a strategic shift in how you engage with and guide your members through the complexities of Medicare enrollment. 

Roadblocks to Increasing Medicare Member Engagement 

You know that the process of developing Medicare plans can be demanding and stressful, especially with disjointed systems. It’s a full-time job to enable members to retain their current (in-network) providers, to curate drug formularies, and meet regulated timelines. It doesn’t have to be, though. With the lack of integration and siloed processes, your current enrollment tools can’t harness essential claim data that’s locked within your core systems. This limits your capacity to make personalized plan recommendations. By dismantling these silos, you can unlock valuable and necessary insights, empowering you to provide guidance to your members during the Medicare plan selection process. 

Cognizant’s Medicare Navigator, Powered by SmartIQ™ 

Streamlining the enrollment process for your Medicare Advantage (MA) plan can make all the difference. The American Economic Association emphasizes that reducing customer effort leads to higher completion rates. Building on this, Forrester’s body of research has consistently shown that enhancing customer experience aids in retaining existing members and expanding your market share in the fiercely competitive MA landscape.  

The stickiness of MA plans offers a unique advantage, creating members for life and boosting Customer Lifetime Value (CLV) due to their higher profitability compared to commercial plans. With a simple, efficient enrollment process, you position yourself for greater competitive differentiation in a crowded marketplace, where happy members become your advocates. 

The good news is that the technology now exists to help you leverage members’ historical claim data, enabling you to identify the best plan option(s) for them. Cognizant’s Medicare Navigator, powered by our SmartIQ software, provides a friction-free process for your members to select and enroll into a plan. Together, we can integrate the front-end plan selection process seamlessly with solutions such as TriZetto® Elements Enrollment Administrations Manager (EAM) to streamline operations. Ultimately, a better process for enrollments will increase retention and profitability. 

Addressing Fear, Uncertainty, and Doubt 

If you’re on the verge of losing members as they transition from commercial plans to the Medicare population, Smart Communications’ leading solutions are the key to boosting your conversion and retention rates. While your competitors lack the tools, experience, and relationships needed, we, in partnership with Cognizant, provide solutions that set your business apart. 

Through our large partner network and the integrations that make possible your Medicare member engagement goals, our solutions offer more than the necessary functionality. We’re uniquely positioned to help your organization shine in the eyes of prospects, current members, and the C-Suite. 

And the best part? Our sophisticated cloud software has been proven to save money for enterprises in highly regulated industries, freeing up valuable resources for the initiatives your company leaders keep striking out of the budget. It’s time to embrace a cloud solution that not only enhances Medicare member engagement but also propels you toward professional success. 

RELATED READING | ‘Forrester Opportunity Snapshot: Disjointed Experiences Cost Insurers Members and Money’ 

Conclusion 

You’re on a mission to boost senior market enrollment and retention, but member fear, uncertainty, and doubt (FUD)— coupled with past experiences with commercial plans— are roadblocks. The key lies in enhancing the plan selection and enrollment process and offering personalized plan recommendations based on individual claim histories to foster trust and convert commercial members into Medicare Advantage (MA) members. 

Partnering with Cognizant, we’re here to guide you through the entire process, from segmentation and outreach to plan selection and enrollment. Cognizant’s research validates our approach, analyst accolades showcase our capability, and customer testimonials, including success stories from healthcare payers like you, assure success. 

Streamlining the enrollment process holds the promise of lower abandonment rates, higher conversion rates, upselling opportunities, and reduced administrative costs. 

The cost of doing nothing outweighs the benefits of taking action. The resulting revenue and savings not only mitigate opportunity risk but also secure your position. It’s time to turn challenges into triumphs with a solution designed to drive Medicare engagement. 

To learn more, access the on-demand webinar with Cognizant and Smart Communications hosted by Fierce Healthcare or request a demo of SmartIQ for Enrollment.

The Top 5 Takeaways from Guidewire Connections 2023

Posted on by Eileen Potter

By Eileen Potter, Vice President of Insurance Marketing at Smart Communications

Guidewire Connections 2023 was an amazing experience, once again raising the bar for an industry conference. We enjoyed three days of conversations with customers, prospects, analysts, and partners, along with inspiring keynotes and a lot learning.

There were too many great moments to mention them all here, but some personal highlights were moderating a panel with Shawn Antao from EY and Karen Hopkins-Lee from Premier Insurance, presenting in the Demo Theater with my colleague Andrew Cortright, and seeing our customer Tim Hays from Mountain West Farm Bureau onstage with Guidewire’s Daniele Groves, talking about how to strategically build your Guidewire ecosystem. 

It’s never easy to narrow down the highlights from such an event, but here are the 5 things that resonated with me:  

1. Innovation Takes Center Stage 

Guidewire Connections 2023 wasn’t just a conference; it was a showcase of innovation at its finest. From cutting-edge technologies to cutting-edge business models, the event was a testament to the industry’s commitment to staying ahead of the curve.  

2. Digital Transformation Accelerated 

We all knew that digital transformation was the name of the game, but at Guidewire Connections, things shifted into high gear. Insurers are not just dipping their toes into the digital waters; they’re diving in headfirst. The buzzword of the moment? AI, of course. But what impressed me the most was how insurers are more open to creating a technology ecosystem that will enable them to scale – and, keep them agile for future change. Innovation is now firmly integrated into the industry’s DNA. 

3. Customer-Centricity Reigns Supreme 

No surprises here – customer-centricity continues to be the Holy Grail of the insurance industry. But what stood out at Guidewire Connections was the genuine commitment to putting customers at the heart of every decision. Insurers are no longer just service providers; they’re experience creators. The focus on personalized, frictionless customer journeys left me feeling optimistic about the future of insurance. 

4. Data, Data, Data: The New Currency 

The emphasis on data analytics and insights was impossible to ignore. Insurers are not just collecting data; they’re leveraging it to drive strategic decision-making. The shift from reactive to proactive risk management is real, and it’s powered by the mountains of data being generated and analyzed within the industry. 

5. Collaboration is Key 

The theme for the conference was the Power of Community, and in the spirit of “we’re all in this together,” collaboration was a recurring talking point throughout the event. Insurers are recognizing that they can’t go it alone in this rapidly evolving landscape. Partnerships, ecosystems, and cross-industry collaborations were not just discussed; they were celebrated. It’s refreshing to see competitors becoming collaborators, all with the shared goal of creating a more resilient and innovative insurance ecosystem. 

Guidewire Connections 2023 reflected the best of the insurance industry: Insights, innovation, and inspiration – and partnership. I am extremely proud that Smart Communications is a Guidewire FY23 PartnerConnect Partner Excellence Award winner: named the “Ecosystem Partner of the Year” for outstanding achievement and adherence to project requirements, joint customers, and FY23 Marketplace data.

As we move towards 2024, and navigate the ever-changing landscape of Insurtech, these takeaways serve as a compass, guiding us toward a future where insurance is not just a safety net but a proactive, customer-centric force for good. Cheers to the future of insurance, and here’s to Guidewire Connections 2024 – may it be even more groundbreaking than its predecessor!