Healthcare Member Communications Are Ripe for Transformation – Are You Prepared?

Posted on September 25, 2023October 19, 2026 by Smart Communications Team

By: John Zimmerer, VP of Industry Marketing, Insurance at Smart Communications

As parts of the world begin to open up, it’s easy to think that life, for both businesses and consumers, can simply pick up where we left off. But to do so would ignore the opportunities for improvement that we were forced to explore during the worst of the pandemic. One key lesson at the top of our list? The need for healthcare payers and providers to focus on timely, relevant and personalized member communications. While the pandemic provided the catalyst to accelerate the implementation of better digital conversation experiences, there’s still a long way to go, as revealed by data from J.D. Power:

54% of members do not understand if telehealth services are covered
48% believe the payer has not shown concern for their health since the pandemic began
Only 25% view the payer as their trusted partner
Only 36% feel the payer acts in their best interest

Clearly, there are major gaps in the way healthcare payers and providers think they are communicating to members, and how members are actually receiving those messages. In fact, recent research revealed that 63% of businesses think they are delivering excellent or very good communications to their customers, but only 51% of consumers give the same ratings to the communications they receive.

In a recent panel discussion at the Cognizant Healthcare Conference, three Smart Communications experts shared their perspectives on how the healthcare communications landscape is changing, and what leading payers and providers need to do to transform member experiences. While we invite you to view the full recording below, this post also highlights some of the key takeaways from the discussion and some best practices for delivering two-way, digital conversations.

Key Challenges Accelerating the Pace of Communication Transformation

The J.D. Power statistics show us that trust is low, and key messages, like those around telehealth coverage, are being missed or fall flat. Historically, this has been caused by both technological and operational limitations:

Static, mass email blasts to all customers delivering the same high-level messaging regardless of individual circumstances
Disconnected communication experiences that force members to provide the same information again and again across channels
An over-reliance on print for communicating key messages instead of a multichannel approach based on a customer’s stated preferences

These challenges have been felt across the four key areas of the healthcare member experience where it is most important to get communications right: member acquisition and enrollment, onboarding, care management and claims. If customers feel like they’re having suboptimal experiences everywhere they turn, it’s no wonder their frustration results in lower scores on the most critical customer satisfaction metrics.

Creating SMARTER Member Conversations

The good news is that many of these challenges can be solved. Leading payers and providers are taking the steps necessary to overcome traditional challenges and build the technical and operational infrastructure needed to transform the future of healthcare communications.

One powerful example of how to achieve the dream state of SMARTER customer conversations comes from Blue Shield of California, as shared at INNOVATE 2021. In their quest for 95% of communications to be digital-first, they pursued the following principles for success:

Make it Simple – only deliver communications that solve or pre-empt members’ needs and expectations. Rely on dynamic templates that drive consistency across channels but also increase agility. Then, streamline preview and approval processes.
Make it Useful – only deliver communications that provide relevant information in every channel, based on a combination of stated preferences and insights derived from advanced analytics.
Make it Mine – only deliver communications that are personalized, while keeping security top of mind.

These guiding principles are an important starting point for the larger question healthcare payers and providers are focused on – where are the biggest opportunities for improvement?

Here are just a few examples of how digital optimization can make a huge impact, along with real-world results:

Collecting Open Enrollment Choices Digitally

As the largest customer-owned health insurer in the U.S., supporting 140,000 employers across 5 states, Health Care Service Corporation (HCSC) realized the importance of transforming its open enrollment processes. HCSC had 250 manual, static forms which contained 20 unique sections with 3,000 different attributes that needed to be delivered to 26 downstream internal and external customers. The need for a highly scalable solution was especially evident here. HCSC worked with Smart Communications to eliminate manual forms in favor of a single, guided, digital interview process.

Using SmartIQ^TM, HCSC eliminated manual re-entry, reduced their support team training time and increased the amount of time employers had to make decisions, ultimately increasing productivity while lowering cost. Learn more about HCSC’s success in Transforming Manual Forms Processes into Exceptional Digital Experiences from INNOVATE 2021.

Streamline the Contract Generation Process

A leading managed healthcare and insurance provider sought to digitally optimize and improve their employer-sponsored plans. By working with Smart Communications, they managed to optimize a manual contract generation process involving multiple internal and external groups that took 2 weeks to just 1 business day—a 90% increase in efficiency. Additionally, when used in combination with SmartCOMM^TM for Salesforce, they were able to generate a contract in only 30 minutes, a dramatic improvement from where they were.

Globalization and Optimization Across the Enterprise – at Scale

The ability to optimize across multiple brands, jurisdictions and languages can vastly improve efficiency while reducing cost. By leveraging approachable technology, payers and providers can also optimize their workload throughout the organization, instead of being in a situation where certain tasks can only be completed by IT or specific subject matter experts.

With healthcare communications at an inflection point, taking proactive steps to align technology and operations for an optimal member experience is essential. And the cascading business benefits are measurable.

If you’d like to learn more about transforming healthcare member communications, check out our white paper “From Onboarding to Lifelong Relationships.”

3 Ways a Better Digital Forms Experience Helps Health Payers Increase Star Ratings

Posted on March 27, 2023October 19, 2026 by John Zimmerer

By: John Zimmerer, Vice President of Healthcare Marketing at Smart Communications

Star Ratings are a critical aspect for customers when evaluating health insurance plans as they help consumers make informed decisions about their health coverage. To increase enrollments, insurers should strive to keep their Star Rating above a 4.0, but they also need to think about the existing customers they serve. That means enhancing the overall customer experience and increasing customer loyalty, sometimes a tough ask with constantly shifting regulations and the need to accelerate digital transformation weighing on organizations.

In this article, we talk about how insurers can increase their Star Ratings by focusing on one of the top contributors to the overall customer experience: communications. To provide excellent communications across all channels where members interact with the business, health insurers need to help members feel seen and known as individuals. This starts with developing a strong customer communications strategy, made possible by leveraging pure cloud CCM solutions. As part of that communications strategy, insurers also need the proper forms solutions to gather member data and put it into action while ensuring they’re compliant and secure. Keep reading to learn the three ways a better digital forms experience helps to increase Star Ratings and customer loyalty, but first, we’ll touch on why Star Ratings matter.

Why are Star Ratings Important for Health Insurers?

Measures quality of care: Based on various factors—such as preventive care, patient experience and medical outcomes—Star Ratings give consumers a comprehensive picture of the plan’s performance. This information can help consumers choose the best plan for their needs and ensure they receive quality care.

Promotes competition: Star Ratings create competition among health insurance providers, encouraging them to improve their services and invest in the systems and processes that help them support their members. As a result, members benefit from a wider range of high-quality options and can choose the plan that best fits their needs.

Improves transparency: The ratings provide a clear, unbiased assessment of the quality of benefits and services offered by health insurance plans, which can help consumers compare plans and make better-informed decisions about their health coverage.

Supports evidence-based decision making: Star Ratings are based on data, including patient surveys and medical records, which helps to ensure that the ratings are accurate and factual. This data-driven approach supports evidence-based decision making and helps consumers choose the best plan for their needs, an especially important factor considering the growing digital native cohort who’ve become accustomed to making decisions quickly.

YOU MIGHT ALSO LIKE | ‘4 Ways Forms Automation Can Enhance the Healthcare Member Experience‘

1. Digital Forms Can Help Address This Customer Driver Behind CX and Loyalty

As of 2023, Star Ratings have become more impacted by customer experience (CX) with member experience metrics making up 57% of Star Ratings for Medicare Advantage plans. Considering 1 in 3 customers will leave a brand they love after just one bad experience, it’s critical to avoid situations that can lead to this. With that said, effective customer communications management is key to providing a positive customer experience. Health insurers should aim to provide clear and concise information about their plans, including claim-related communications. The requirement to provide personalized communications, tailored to the individual member’s needs, also extends to forms processes.

For example, claims appeals can become tricky when using traditional methods of communicating between a member and the payer. When questions arise, members are typically instructed to contact a call center and find, fill out and submit a generic appeal form to request redetermination. This multi-step approach increases the customer effort (another factor that impacts Star Ratings) and ultimately leads to frustration. However, this form is an important piece of information during the redetermination process and can’t be overlooked.

Using a digital forms solution, on the other hand, allows members to engage in an intelligent interview that provides a guided experience. A link to the interview can be embedded directly into the Explanation of Benefits (EOB). After submitting their responses to the interview, members can download a copy of the appeal form for their records. By integrating the interview with core systems, an Appeals and Grievances staff member can be notified of the submission and start the review process. This allows insurers to provide members with a self-service option and save time and money by removing steps related to receiving, scanning and routing paper forms.

2. Build Loyalty by Helping Customers Understand Their Plans

Health insurance can be a confusing and complicated topic for many consumers. With many different plans and options available, it can be difficult to understand exactly what is covered under a particular policy and what out-of-pocket costs might be incurred. However, health insurers can build loyalty by helping their customers understand their health plans and making the process of navigating the healthcare system easier.

One way to do so is by providing clear and concise information about the different aspects of a health plan. This might include easy-to-understand descriptions of coverage options, deductibles, copays and other terms that are commonly used in the healthcare industry. By providing this information in a format that is easy to understand, payers can help customers feel more confident in their decision-making and more comfortable with the choices they have made. This enhances the overall member experience, thus, increasing loyalty and customer retention.

In addition to providing clear information about the details of a health plan, health insurers can also help their customers understand the broader healthcare system. For example, they can offer resources and tools that explain how to find a doctor, how to schedule appointments and how to access other benefits. By offering this type of support, customers will feel more empowered and in control of their healthcare experience, including having more options to easily self-serve when necessary.

Offering personalized support and guidance will require the right systems and processes in place, like SmartIQ, a sophisticated digital forms solution. Providing this type of personalization, health insurers ensure customers feel heard and valued, and can establish a deeper connection with their members. Straightforward information about the costs of healthcare services, and clear explanations about any restrictions or limits on coverage, will help build trust and establish a strong relationship with their customers.

3. Create a User-Friendly, Digital Forms Experience

The member’s experience with forms is measured by the CAHPS surveys and translates to the customer service metric in the Stars Rating. When providing interacting with a health-related form, everything from which colors are used to font sizes and the information architecture influence a member’s perception of the brand. All are also key factors in creating user-friendly forms experience. But, how do health insurers know what to look for when creating responsive and user-friendly digital forms that elicit a positive response from members? The good news is, a pure cloud forms solution enables organizations to create a truly responsive forms experience, meaning it will look and operate the same across all platforms and channels. A few things to keep in mind:

Use what you know. Leverage integrations with core systems and single sign-on to pull data into forms so that members can review and revise rather than rekey this information. This will reduce the member’s effort as well as the opportunity for data entry errors.
Make the form visually appealing. Use a clean and organized layout, including clear headings/subheadings, helping customers quickly find the information they need. Consider using colors and images to make the form more appealing and easier to navigate.
Keep it simple and straightforward. Avoid using technical terms/jargon that may be confusing or misleading to customers. If specific terminology must be used, be sure to provide clear explanations of any terms that may be unfamiliar to customers. This includes using help text in the form.
Make the form accessible. Ensure all digital forms are accessible to customers with disabilities; this isn’t simply a nice-to-have, it’s a must-have, given 508 compliance mandates. Use appropriate formatting, like larger text/high-contrast colors, and include alternative text descriptions for images. We offer a guide to help make SmartIQ interviews WCAG-compliant.
Validate information in real-time. Use real-time validation to alert customers of any errors or missing information as they complete the form. This helps reduce the risk of errors and ensure that the form is completed correctly the first time, diminishing the chance for customer frustration and/or eliminate delays.

The above list is not exhaustive by any means but it’s important not to overlook this key point to enhancing star ratings and customer loyalty. In fact, 60% of customers will abandon a form if the process is too difficult—something that could be mitigated by deploying modern forms that are easy to engage with. The right vendor partnership will help insurers optimize the systems and processes they use to interact with customers, including the user-friendliness of their forms experiences.

**If you’d like more information on Star Ratings, customer experience and how to enhance member loyalty, watch the webinar recording of ‘Latest Benchmarks & Top Priorities for Health Payers’ featuring Judy Weader from Forrester Research. If you’re ready to take your health insurance organization to the next level.**

Provide the Ultimate Healthcare Customer Experience

Posted on September 14, 2022October 23, 2026 by John Zimmerer

Provide the Ultimate Healthcare Customer Experience: The Guide to Member Engagement Strategies

By: John Zimmerer, VP of Healthcare Marketing at Smart Communications

In a world where everyone is always on the go and as technology becomes smarter, faster and more intuitive, consumers increasingly prefer—and expect—digital-first experiences.

For highly regulated industries like healthcare, the stakes are even higher. Everyday customer interactions can be stressful, making the experience that health insurers provide at every touch point more important than ever. Recent benchmark data confirms this – with 81% of consumers indicating that communications are important to their overall experience with a company.

Unfortunately for healthcare payers, the industry lags in digital adoption, which has led to both internal inefficiencies and poor customer experience. As they interact with other non-healthcare industries that have set the customer experience bar high, healthcare members may begin looking to competitors to fulfill their needs. According to the Forrester Customer Experience Index, healthcare tracks well below the averages of most, ranking tenth out of the 13 U.S. industries analyzed.

In Provide the Ultimate Healthcare Customer Experience, we will walk through:

Key customer experience trends in healthcare
How healthcare payers can increase member engagement via cloud-based technology
The importance of omnichannel customer communications
Why Smart Communications offers the most complete platform on the market to support leading health insurers’ business strategies

Changing Customer Expectations and Regulations Drive Trends in Healthcare

The past few years have amplified the need for improved customer interactions. Globally, businesses have faced—and in many ways continue to endure—disruptions on multiple fronts. Many employers have moved their entire workforce to function as fully remote teams while continuing to navigate what the “next new normal” of work might look like. While all of these macro forces were influencing organizations to rethink how to do business, customer demands for digital-first experiences continued to increase.

Compounding to this digital transformation, the healthcare industry saw new regulations put in place, including:

Interoperability, which is “the ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner,” according to HIMSS
Price transparency, which allows healthcare patients to know the cost of a medical service before receiving it
Value-based care, where healthcare providers and hospitals are paid based on patient health outcomes
Shift to Medicare Advantage and ACA plans, providing individuals with more choices of health plans to purchase

As a result of these ever-changing market conditions, even the U.S. Federal Government has come to understand the importance of how much the customer experience matters to consumers when choosing a healthcare plan: for the 2023 plan year, member experience metrics make up the largest percentage (57%) of star ratings for Medicare Advantage plans.

Customer Experience Trends in Healthcare

On the bright side, insurers are beginning to realize the importance of making the healthcare customer experience a strategic priority. Recent findings include:

More focus on improving customer interactions. A Forrester report revealed that 15 out of the top 17 health insurers have experienced as much as a 5% year-over-year increase of their CX index scores – in large part due to these concentrated CX investments.
Higher investments in “total experience solutions.” These “consumer engagement” solutions improve the experience for both the employee and the member and are one of the top investment targets for health payers, according to Gartner.
Stagnant budgets. The same Gartner survey revealed that healthcare payers are seeing the lowest technology budget increases of any other industry. Health insurers therefore must invest wisely, strategically selecting key areas to improve that maximize the impact on the customer experience while minimizing disruption to both their members and their own organizations.

So, how can health insurers set themselves up for success?

A cloud-based platform that optimizes the end-to-end healthcare customer experience provides the agility, flexibility and innovation that homegrown or legacy, on-premise systems cannot. Below, we will dive into the benefits of cloud for nearly every touch point in the member journey, plus how optimized member communications provide health payers with the competitive edge they’re seeking.

Convert One-way Customer Communications to Two-way Conversations

To positively impact the healthcare customer experience, payers need to focus their investments in transforming their member communications. Leading analyst firms like Forrester confirm this, with recent research indicating that one of the top drivers of delivering a better customer experience is related to improved member communications.

Forrester also cites consumer preferences like “respects me as a customer” and “effective website and mobile apps” as factors that positively impact health payers’ experience scores.

To do this, health insurers must keep member preference in mind – at every step of the experience. Members should be able to start and stop interactions across channels and devices without having to re-key information. Delivering communications based on channel preference is also a must, as 61% of consumers indicated that receiving messages on the wrong channel leads to frustration with a company. At the end of the day, effective member conversations require an efficient and accessible digital experience at every step of the process.

Unfortunately, traditional ways of communicating with members aren’t as effective as they once were. So, as insurers rethink the healthcare customer experience, that means reimagining how members interact at every touch point. A big part of this is shifting from one-way, transactional communications to two-way, interactive conversations.

Delivering personalized, relevant and compliant conversations at scale can feel daunting, but the health insurers that invest in pure cloud solutions that are purpose-built to optimize member conversations will be set up for success. Cloud platforms, like the Conversation Cloud^TM, enable quick innovation, agility, scalability – and most importantly allow health insurers to evolve and scale as members expectations change over time.

RELATED READING | INFOGRAPHIC: Optimize Member Engagement at Every Point of the Health Insurance Journey

The Conversation Cloud^TM for Health Insurers

The Conversation Cloud^TM from Smart Communications empowers insurers to maximize their investments in the healthcare customer experience. Whether transforming a micro moment, such as a member-submitted claim form; to improving the access to and readability of critical communications like an Explanation of Benefits; or to orchestrate an entire customer journey such as a claim redetermination, look to the Smart Communications Conversation Cloud.

To better understand how the Conversation Cloud provides improves and transforms one-way communications into two-way, interactive conversations that positively impact the customer experience, this article focuses on four key areas where health insurers can enhance processes today:

Collect: Improve Data Gathering
Communicate: Increase Member Engagement with Content
Collaborate: Redefine Stakeholder Engagement
Coordinate: Reimagine the End-to-End Healthcare Customer Experience

Each section of this article provides examples and information to help insurers identify possible areas of investment, and in the process convert traditional communications into real-time, two-way conversations.

Collect: Improve Data Gathering

As health insurance executives start to invest more heavily in digital, they want to ensure that their investments are making a difference.

In a survey of more than 100 health insurance and provider executives, respondents cited what their organizations are currently doing and where opportunities still exist for improvement. When examining these leading indicators that impact the overall strategy for digitization investments, it’s no wonder that “customer satisfaction” is at the top of the list.

Despite more priority and effort going into customer satisfaction, this ongoing goal is simultaneously an ongoing challenge. Several points of friction are still holding digital projects back from making consumers happy. As companies expand their investment footprint across online and offline touchpoints, removing those frustrations is even more essential.

The Impact of Forms Automation on the Healthcare Customer Experience

Forms are a great example of one important aspect of a larger member journey. At some point, insurers will need to collect personally identifiable and protected health information (PII and PHI, respectively) from members. Most of the time, it’s done via a form—like web “name, address, location” fields, a PDF document, or just simply a piece of paper.

RELATED READING: Optimize Digital Forms for COVID-19 Claims

One of the greatest points of friction for members is having to provide the same data—name, address, age, etc.—repeatedly within and across forms. Consumers have a simple request: ‘Show me you know me’. Healthcare companies most often already have the data through direct engagement, an employer, provider, insurer or relationships with third-party providers.

The first trick is in making the digital connection to existing data; the next is to use this data intelligently. That means using available information and logic to hide or show subsequent questions or input fields. It also means leveraging integrations with other third-party services (for example, autocompleting address information, scanning a barcode, validating bank or other account information, etc.) to significantly reduce customer effort and enhance the customer experience.

Challenge

Static forms and similar tools can be cold and off-putting, therefore becoming a barrier to good data collection. To state it bluntly: customers just won’t fill them out.

Solution

The Conversation Cloud allows health insurers to seamlessly collect customer information by transforming static forms-based processes into intelligent, conversational user experiences. SmartIQ^TM powers:

Adaptive interviews
Experience-driven interactions
Omni-device availability
Real-time data validation

How can insurers use forms automation to enhance the healthcare customer experience?

Submit/appeal a claim
Disclosure and consent forms
Prior authorization requests
Personal representative appointment

Interested in learning more? Check out four ways forms automation can enhance the healthcare member experience.

Communicate: Increase Engagement with Tailored, Omnichannel Content

Personalization is a prevailing tactic for healthcare’s move toward digital excellence, and it’s easy to see why: When consumers receive relevant (customized) content on the right channel at the right time, they’re more likely to act and respond.

The two most frequently used digital communications tactics in insurance and health organizations are personalized messaging and multiple format options to support delivery across channels.

Supporting omnichannel engagement can also help organizations make the transition to a self-service model. Customers overwhelmingly prefer a digital-first approach including apps or online portals that give them more autonomy.

RELATED READING: How enterprises can orchestrate effective omnichannel conversations, creating consistent, customer-driven experiences across channels.

As a result, healthcare members want options: mobile phones, tablets and wearables have created an “always-on” environment where they can get things done with a click of a button. Access to multiple channels—plus ever-increasing expectations—puts more pressure on customer communications.

Successful conversations require content that is readable and easy for the user to comprehend. To keep customers engaged throughout the process, communications must be tailored as much as possible to the individual reader. These all must happen in real-time and must be able to reference context from previous interactions.

Getting these conversations done correctly and with ease is crucial for successful interactions. As insurers are looking to align their business priorities with member expectations, it’s important to keep in mind that 60% of healthcare consumers recently surveyed indicated that improving relevance and personalization is a top priority.

Challenge

Though these interactions are often mission critical, delivering personalized, real-time, contextual communications usually requires the creation and management of complex IT processes.

Solution

The Conversation Cloud empowers health insurers to create and deliver personalized, contextual and compliant communications across preferred channels to improve healthcare customer experience and deepen loyalty with:

Omnichannel approach for customer-preferred devices
Templates and reusable objects for consistency and compliance
Integrations with systems of record to pull in data for personalization
AI to improve readability and provide engagement insights

Ultimately health insurers can leverage these Communicate features across use cases, including:

Enrollment (ANOC, EOC, SBC, etc.)
Onboarding (ID card, provider/pharmacy directories, etc.)
Utilization (notifications/reminders, care management plans, etc.)
Claims (EOB, EOP, letters, etc.)

RELATED READING | Exploring CCM solutions? The Ultimate Guide to CCM Software provides a high-level overview of CCM software, poses questions to ask when selecting a vendor and more.

Collaborate: Change Stakeholder Engagement

Customer conversations sometimes require interacting with multiple stakeholders in a nonlinear process. Often, interactions occur outside the company altogether, e.g., with partners or regulators. Unfortunately, many businesses do not have a way for stakeholders to collaborate on business processes, which leads to a disjointed, frustrating customer or employee experience.

As a result, many fail to provide a holistic view of who made changes to critical documents, including what and when these changes were made. Requesting signatures or additional information from relevant parties can be difficult and these outdated processes can make sharing confidential information a security concern as well.

Challenge

When multiple stakeholders are involved in a process, there is increased risk of error – or worse – compliance issues. Siloed systems and inefficient processes are also time consuming, open up room for version control issues and create poor member and employee experiences.

Solution

Not only can the Conversation Cloud help speed things up, but it can also make these multi-step processes easy and simple, which results in a more efficient and effective interaction for all parties involved.

Working in a secure, online environment eliminates version control issues and also helps ensure compliance standards are met. With the Conversation Cloud, health payers can negotiate and execute processes by negotiating and providing business-critical agreements across internal and external stakeholders using experience-driven workflow including:

Developing Plan Documents
Coordinating Plan Selection for Group Enrollment
Internal Review and Approval of Content or Communications
Regulator Review of Plan Documents
Negotiating Provider or Supplier Contracts

RELATED READING | Healthcare member communications are ripe for transformation – are you prepared?

Coordinate: Reimagine the End-to-End Healthcare Customer Experience

Health insurers must focus on orchestrated, omnichannel interactions that guide customers through critical processes and provide richer, deeper and more engaging experiences. By interacting with customers via their preferred channels, health payers can improve their overall experience and increase brand loyalty.

Smart Communications partnered with Forrester Research to examine the current state of customer experience in healthcare. This research found that although 63% of consumers want better-connected journey touchpoints to improve the member experience, 57% of health insurers are struggling with the ability to provide a seamless digital experience throughout a given customer journey. The research also found that payers provide poor personalization and that journeys involving forms are as troublesome for insurers as they are for members and partners:

By creating self-service workflows and connecting across organizational silos, insurers can help their customers get easy questions answered, or simple steps completed—such as benefit or claim inquiries—in as few (or preferably single) interactions as possible. Although this compression of customer journeys can cut out unnecessary steps or to remove delays, the underlying and greater emphasis is on removing friction that leads to a lowering of effort on the member’s part (i.e., the ease and effectiveness factors most favorably into the overall customer experience).

Members focus on moments that matter—the interactions and processes which are valuable or necessary to achieving a goal. As insurers are looking to make the healthcare customer experience more omnichannel, some key questions they should ask themselves include:

Are the required steps to achieve common goals clear?
Are we maximizing integrations to minimize customer effort?
Are there steps in critical customer journeys where customers are falling off or feeling frustrated?

Challenge

The business (and the customer experience) can be negatively impacted when processes break down or a deadline passes.

Solution

Orchestrate interactions to optimize the customer experience across devices and channels with:

Facilitated two-way conversations
Failover from preferred to fallback channels
Analytics and insight into member engagement

Enterprises should invest in and prioritize technology solutions that evolve and scale as customer expectations change over time, delivering interactive, two-way conversations that encourage engagement and brand loyalty.

Conclusion

Changing the Conversation in Healthcare

Health insurers can improve customer experience by removing friction and delivering personalized communications in real-time, via any channel, and at scale that are:

Customer-driven
Digital-first
Two-way
Relevant and contextual
Cloud-centric
Highly scalable
Omnichannel

At Smart Communications, we have the products, professional services and partner network to help insurers improve the healthcare customer experience, whether it’s to coordinate an entire member journey or to improve how customer information is collected. Contact us today to discuss where to begin.

Smart Communications for Healthcare

Certifications

The Conversation Cloud is the only secure customer conversation management platform to have achieved an independent third-party validation of HIPAA, PCI-DSS, ISO and SOC compliance.

Customers

Our healthcare customers choose Smart Communications because they want to improve their customer experience, or they want to improve their operational efficiency. As a result, SMART customers see CX improvements reflected in higher NPS, CSAT and CX Index scores.

Additionally, SMART customers are seeing operational improvements driven by hard and soft cost savings by moving to a centralized cloud-native platform.

Partners

Optimizing the Patient Experience with a No-Code Patient Appointment System

Posted on August 19, 2022October 23, 2026 by John Zimmerer

By: John Zimmerer, VP of Healthcare Marketing at Smart Communications

While the healthcare industry is known for keeping one foot in the past where systems and workflows are concerned, many healthcare providers have begun the process of digitizing processes to enhance the patient experience. This often starts by considering the current way they’re interacting with patients and identifying ways to reimagine the end-to-end patient experience.

In addition to increasingly high patient expectations, this change is also being driven by payment stipulations. Payment often depends on the level of patient satisfaction, especially as the Centers for Medicare & Medicaid Services (CMS) implement “value-based” programs that reward health care providers with incentive payments for the quality of care they give to people with Medicare.

So, as healthcare providers are consistently looking for ways to improve the patient experience, one way to make a quick improvement is to focus on the ways a patient schedules an appointment, which is why a digital-first, no-code patient appointment system should be one of the top priorities for healthcare providers right now. Not only can it enhance the inner workings of a practice, a sophisticated, modern solution can quickly and significantly enhance the overall patient experience. It can also help with:

Allowing patients to book appointments on their own, without being bound to a provider’s office hours
Automatically sending appointment reminders
Patient flow tracking and reporting, as well as billing integration
Improving key areas of the patient experience like intake, care management or discharge

In this post, we’ll look at the available options and provide tips on how to choose the best patient appointment system for a single practice or an entire system.

Available Patient Appointment Systems on the Market

Below are the most widely used patient appointment systems. We outline the pros and cons of each, and detail why a no-code approach is the best long-term strategy for healthcare providers.

Scheduling modules included with EHR/EMR systems

Athenahealth, Cerner, Epic and other systems offer patient scheduling modules. Resources such as EHR in Practice do a good job of comparing these systems. While each has its strong points, the biggest challenge is that the modules all look and operate differently. In some cases, the modules work differently on a desktop than on a mobile device.

Consistency is an important aspect of a great patient experience. For providers that have two or more EHR/EMR systems, the appointment setting experience will be different with each; thus, lacking the consistent experience needed. This means it isn’t a user-friendly approach for the practice nor the patient. A truly responsive patient appointment system should look and operate the same across any platform.

Dedicated patient appointment systems

There are several options when it comes to choosing a dedicated scheduling system—resources like Captera and SelectHub can provide insights into each. The biggest benefit of using a dedicated system is that the experience will be consistent across providers and practitioners, as these systems integrate with the major EHR/EMR systems. The largest limitation is that most of these systems only solve for scheduling and cannot be used to address other forms-based use cases such as intake, care management or discharge. That means that at least one other system will need to be procured, defeating the goal of simplifying the technology architecture. It also means more of an IT and financial investment will be necessary to implement, deploy and maintain the system.

Open-source patient appointment projects

There’s a plethora of PHP- and Java-based open-source scheduling projects available. Providers with a large enough IT staff may be tempted to implement one of these options. But, there are two pitfalls with going this route. First, it may be difficult to overcome privacy and compliance concerns raised by InfoSec, Legal and Compliance departments. Second, these projects instantly become maintenance burdens. In addition to testing new releases, IT staff will need to regularly redeploy and reintegrate these packages, making what may have started out as ‘freeware’ turn into costly projects that are difficult to budget for in the future.

As each one of these options has significant drawbacks and limitations, none qualify as the best patient appointment system. Luckily, there’s another solution that leverages no-code technology in order to offer flexibility and ease of use.

No-Code Patient Appointment System Enhances the Healthcare Patient Experience

A low-code/no-code solution like SmartIQ^TMoffers the most benefits to healthcare providers when it comes to appointment scheduling – and all of the patient interactions thereafter. Leading healthcare providers like Sonic agree as they partnered with Smart Communications to develop their appointment-setting solution to schedule COVID-19 immunizations.

While our patient appointment system solves many challenges for healthcare providers, some of the main benefits include:

No coding required. Response-based forms require zero coding for most use cases, and low-code support for more complex use cases. Business users—not IT—are able to quickly develop and deploy solutions.
Integration with patient portals and EHR/EMR systems. SmartIQ uses RESTful services for direct integrations and is available on the MuleSoft Anypoint Exchange, providing integration with leading EHR, EMR and other systems.
Always available on any device. Responsive healthcare communications software allows patients to self-serve, making appointments anywhere, at any time, on any device. Patients can even start on one device and finish on another without losing their place in line or any information they’ve already entered.
Can be used to address other use cases. Low-code forms solutions like SmartIQ are flexible and can be used for more than just appointment setting. Providers have used our solutions to streamline health assessments, care visits and other processes.

An automated, low-code forms management solution is ideal for providers looking to simplify their technology stack and standardize a single platform that is flexible, easy to implement, integrate and simple for patients to use. For the patient, this removes the burden of filling out endless paperwork. On the business side, it allows staff in the contact centers to focus on assisting patients with other things that may increase trust and patient satisfaction—two necessary factors in creating patient trust and comfort.

Conclusion

Smart Communications has helped providers that rely on its ISO-certified and HIPAA-compliant Conversation Cloud platform to provide appointment setting solutions and solve for other form-based use cases. We’ve helped to increase their efficiency as much as 80% and meaningfully improve NPS and other customer experience metrics.

Contact us to request a free live demo to see how you can implement a secure and simple patient appointment system that enhances the patient experience, eliminates friction and creates better patient workflows.

Driving Better Outcomes in Workers’ Compensation

Posted on July 8, 2022October 19, 2026 by Smart Communications Team

By: Ruth Fisk, VP Insurance Strategy at Smart Communications

Reimagining communications is critical to controlling costs and improving business outcomes

For many years, digital transformation has been a common strategic initiative, spanning just about every industry. But unfortunately, insurance has been slow to the game. At the same time, increasing costs, complexity and regulations are making insurance processes more complicated and compliance more critical, while consumer expectations for seamless digital experiences are extending into more traditional businesses like insurance. More than being compared simply to one another, today’s insurers are competing with every customer’s last, best experience with digital-first companies like Uber, Instacart, Waze and others. The time is now for the industry as a whole to take a more innovative approach.

When it comes to workers’ compensation insurance, insurers need to look for new, more digitally-driven ways to manage claims and control costs. In addition to supporting better life outcomes for injured workers, processing claims in a more efficient, timely manner enables insurers to drive better business outcomes—for both the injured worker and the employer.

There are a number of areas within workers’ compensation where insurers can streamline processes, including:

Accelerating initial reporting processes
Increasing claimant responsibility through self-determination programs
Enhancing information and analytics for treatment plans
Focusing on rehabilitation, as well as more preventative measures, and increased loss control

Every facet of this forward-thinking approach centers on one key aspect of the interaction: interactive, two-way conversations. In workers’ compensation, every customer touch point is critical. In this high-stakes, emotional and stressful situation, insurers have an opportunity to build trust and make processes smooth, efficient, fast and empathetic.

Let’s look at how improved, digital-first interactions drive better outcomes for everyone involved in a workers’ compensation claim.

Supporting the Injured Worker

Being injured on the job creates difficulties on multiple fronts. In addition to dealing with the stress of a medical situation and all that entails, including pain, discomfort, appointments, recovery time and more, injured workers are worried about the impact the incident will have on their lives. Will they have the ability to support their family? When will they be able to return to work? How will they manage a short- or long-term loss of income?

To minimize stress for the injured worker and help them achieve the best possible personal outcomes as swiftly as possible, claims processes need to be simplified and decisions must be expedited. Digitizing processes and turning static, manual tasks into dynamic, two-way interactions simplifies every step of the claims process and accelerates the path to decisions and settlement, as well as rehabilitation and recovery.

If an injured worker has the right support from their employer and insurer, they can rest easy knowing their income stability will not be jeopardized while they recover from their injury. Digital-first, interactive conversations help to establish this faster, reducing stress during an already stressful time. The medical support they receive will also help them return to work faster—which is ultimately what they want to do.

Improving communications between the injured worker and recommended healthcare providers makes it easier for them to get the care they need to recover. Injured workers should be able to make their own choices about care. This puts them in control of planning their path to rehabilitation and taking responsibility for the return-to-work plan. Opening the pathways of communication between the insurer, the injured worker and the care team empowers claimants and allows them to take this vital control.

Enabling Greater Efficiency for Employers

When a workplace injury occurs, time is of the essence. Employers must report the injury quickly to maintain compliance with regulatory bodies, and also to minimize the costs. Rapid response helps mitigate additional medical costs as well as potential litigation. And delayed reporting can significantly increase workers’ compensation claims costs. Expediting the claim also helps to get the injured worker back to work faster, minimizing productivity and operational continuity losses.

Employers should have the ability to report a claim easily and securely. They should be able to actively participate in reporting the claim as well as in the worker’s rehabilitation and eventual return-to-work plan. Giving employers this ability calls for a reimagining of processes, systems and technology. It requires new solutions that replace outdated, paper-based processes with dynamic, digital interactions.

When employers have the right solutions, they can play an active role in rehabilitation and recovery, helping to improve outcomes for their valued employees as well as for the business as a whole. Workers’ compensation claims management processes are highly regulated and when employers lack solutions that ensure those processes are strictly adhered to, the regulatory cost can be extremely high. Choosing a system that optimizes and simplifies the complexity of communications between all involved parties is critical to success—and to avoiding regulatory fines and expenses.

Improved communications also help employers close claims more quickly. More than half of claims that are reported within the first two weeks close within 18 months. However, only 29% of claims that are reported more than a month after the accident close within the same timeframe.

Empowering Medical Providers for Improved Care

In any workers’ compensation claim, the medical provider plays a key role in recommending what rehabilitation must take place for the worker to return to the job. To expedite claim resolution—and recovery/return to work for the injured employee—medical providers must be able to share information more efficiently and securely.

Improving communications between medical providers and the injured worker, the employer and the case manager all help to expedite claim resolution/return to work and produce better results for all. Replacing manual, analog modes of communication, such as telephone and paper-based forms, with a digital-first approach allows medical providers and case managers to share information quickly, easily and securely. The insurance company’s chief medical officer should be able to seamlessly collaborate with providers to ensure adherence to best practices and facilitate optimal care for the injured worker.

Evidence-based medicine is the cornerstone of the information flow that enables all involved parties to accelerate claim resolution. Being able to share data-driven information with the physician about the most effective treatment plan for similar historical injuries can help providers make an evidence-based recommendation.

A digital-forward solution makes it easy for the physician to upload key information like Certificate of Capacity, medical records, x-ray images and other documents automatically during a guided interview. This information can then be pushed to the claim system (such as Guidewire ClaimCenter) to expedite resolution. Being able to automatically send information to the injured worker’s mobile device as they are leaving the doctor’s office can also help keep their recovery on track and get them back to work sooner. Whether treatment plans, expected return to work data, possible community meetings for similar injuries, or other information, medical providers can serve as a powerful resource encouraging patient progress.

Improving the Options for Case Managers

Case managers are key in streamlining the end-to-end claims management effort. Having access to the right information at the right time can greatly impact the overall process, experience, and outcomes—for both the worker and the employer. Seamless communications between all sources of information (employer, injured worker, care team) and the case manager results in faster claims resolution and happier customers. From collecting initial injury and claim information, to sharing evidence-based medical information with the provider, to keeping the employer in the loop about the expected return-to-work date so they can plan accordingly, an effective case manager can expedite resolution and minimize costs for the insurer.

In addition to improving communications, digitizing processes can help case managers get ahead of potential complications, further mitigating costs and risk. Predictive analytics allow claim managers to identify potential complicating factors about an individual’s condition up front. This enables case managers to take these risks into account from the beginning and create a more proactive approach to the injured party’s ongoing treatment plans.

New technology solutions that are purpose-built for today’s world can transform case management. By automating and digitizing outdated processes, empowering case managers to get the information they need, when they need it, streamlining claims management at every stage and enabling them to drive improved outcomes for all, technology will be instrumental in improving effectiveness.

Driving to Digital with the Conversation Cloud

The Smart Communications Conversation Cloud allows workers’ compensation insurers to turn static forms and disjointed communications into dynamic, on-demand conversations across the entire claims lifecycle. At every stage, improving communications between all involved parties helps to minimize expenses, accelerate resolution and recovery and improve both business and life outcomes.

With pure cloud solutions that integrate with existing systems and infuse intelligence into every step, insurers can dramatically simplify processes to expedite decisions, facilitate faster resolution and make the experience better for everyone. The Conversation Cloud makes it easy to prepopulate forms for more personalized interactions and use automation to boost case manager productivity, while also keeping recovery on track. By harnessing the power of automation to improve communications, maintain compliance and enhance the claims experience and outcomes, insurers have a powerful opportunity for improving workers’ compensation outcomes.

A Time for Progress

The insurance industry has been weighed down by slow, paper-based, disjointed processes for too long. Now is the time for insurers to embrace innovation and take a new approach to workers’ compensation claims management and resolution. For workers’ compensation claims, interactive conversations are the key to creating a better experience, reducing stress and improving the end result for everyone involved.

SMART technology accelerates resolution and minimizes losses for the insured. It has the power to help expedite recovery and improve life outcomes for the injured worker. And the bottom-line benefits of streamlining processes, maintaining compliance and minimizing expenses for the insurer are unmistakable. Adopting a digital-first solution and replacing one-way interactions with dynamic, two-way conversations helps workers’ compensation insurers improve interactions at every step and deliver better results for everyone.

Find out what the Smart Communications Conversation Cloud can do for your business and contact us today.

How to Streamline Health Insurance Policy Renewals

Posted on March 31, 2022October 23, 2026 by John Zimmerer

By: John Zimmerer, VP Healthcare Marketing at Smart Communications

Health payers are always looking for ways to streamline health insurance policy renewals. That’s because the process of renewing a health insurance policy varies widely by line of business. Everything from the set of communications and documents required to how a plan is offered differs from Medicaid to Medicare to ACA-compliant to group plans.

In this post, we look at ways health payers can streamline health insurance policy renewals, saving substantial time and money in the process.

Complying with Rules and Regulations

Some elements of the renewal process are dictated by federal and state governments. For example, in the U.S., Congress, CMS and HHS have a lot of influence on Medicare and ACA-compliant individual plans and supporting materials. And each state puts its own seal, so to speak, on Medicaid offerings. Payers can expend a lot of effort and spend a lot of money each year updating thousands of Medicare and Medicaid templates due to regulatory changes.

Regardless of market or plan type, health insurers need solutions for building and maintaining policy documents and plan communications that:

Enable business users to create and update templates without relying on IT
Leverage reusable content across plan types wherever possible to minimize overhead
Use conditional logic and variables to drive the inclusion of words, paragraphs or sections
Separate brand and style elements from content to make managing multiple brands easier
Include review, commenting and approval capabilities to accelerate workflows
Can evaluate content and recommend changes based on readability, tone and more
Include regression testing to ensure all possible iterations are generated
Provide delivery channel (digital and print) flexibility in the design process
Can orchestrate delivery across channels, including providing fail-over capabilities
Can be deployed entirely in the cloud or in a hybrid model

Speed and agility are essential to health insurers. Getting new plans through regulatory reviews and out to market quickly means processing more renewals, keeping more customers, maintaining underwriting margins and meeting mandated enrollment deadlines. This is especially important for Medicaid and Medicare Advantage plans which have seen enrollments surge in recent years.

In order to operationalize this speed and agility, it’s imperative for insurers to understand their content and where it lives. A visual relationship map of their content can help to accomplish this as well as manage risk. The relationship map helps template administrators understand the shared content objects that make up their templates. When a shared object needs to be updated (e.g., a logo, a signature, a disclaimer, a snippet of text), the changes are automatically applied to all templates that use that object. Using a visual relationship map, template administrators will know in advance which templates will need to be reviewed and approved.

Payers also want to minimize the risks inherent in the renewal process. Missed delivery dates can result in fines and penalties. Errors that creep into the documents can increase print and postage expenses. And enough bad experiences for members can and do translate into lower STAR ratings.

Solutions Trusted by Leading Health Insurers

Our solutions, professional services and partners have already helped dozens of health insurers simplify the task of creating and maintaining the full array of policy renewal assets, including:

Annual Notice of Change (ANOC)
Evidence of Coverage (EOC)
Pre-Enrollment Checklist (PECL)
Notices (e.g., Notice of Privacy Practices, Disenrollment Notices, Non-Renewal Notices)
Provider and Pharmacy Directories
Summary of Benefits and Coverage (SB and SBC)
Summary Plan Description (SPD)

These materials are often based on model documents for each plan type. Insurers need a solution that can import model documents in Microsoft Word or PDF to use as a starting point.

Insurers often need to support multiple brands. Modern customer communications management (CCM) solutions employ a layered model that separates content from styling and branding and maximizes the use of reusable objects. This allows the same content to be created once then used across multiple plan documents. This also simplifies translation efforts and minimizes the effort to comply with accessibility standards.

Plan documents frequently need to go through multiple levels of internal and external reviews. Modern CCM solutions incorporate workflow functionality that can bring internal and external stakeholders together to review, comment on and quickly revise plan documents to get them to market quickly.

Streamline Health Insurance Policy Renewals

Smart Communications has helped to streamline health insurance policy renewals for leading insurers that rely on its ISO-certified and HIPAA-compliant Conversation Cloud platform. We have helped to increase their efficiency as much as 80% and lower the cost to produce renewal-related materials by 50% on average.

Optimize Digital Forms for COVID-19 Claims

Posted on January 21, 2022October 19, 2026 by Smart Communications Team

By: John Zimmerer, VP Healthcare Marketing at Smart Communications

Per the Biden administration’s recent announcement, beginning Jan. 15, 2022, nearly all U.S. private health insurance plans must cover at least a portion of the cost of up to eight at-home COVID-19 tests per month for their members. While the federal government and public health officials have been discussing how to make at-home tests more accessible for some time, the specifics of the rollout were unclear until recently.

There are several conditions in the proclamation, however. For example, not all COVID-19 tests are covered, and not all insurers are required to cover the cost of the tests. There are two types of tests –rapid antigen-based and molecular-based (PCR) – so there are two lists of FDA-approved test kits. A 12-page FAQ defines the insurers covered under the mandate. As the pandemic continues to evolve, we can also expect the government’s expectations and requirements of insurers to change as well. This is putting more pressure on health insurers than ever to scale processes in a way that allows them to be more agile and efficient.

Needless to say, insurers had some homework to do to ensure they could comply with the new mandate. Five days was not much time to put processes and communications in place to handle what will no doubt be many claims for reimbursement. Unfortunately, the current claims experience is relying heavily on manual, paper-based processes. The good news? There is a better way.

In this post, we highlight how health insurers can rethink the claims submission experience, plus why COVID-19 has shed a light on the need for digital forms transformation.

Background Information

To be reimbursed for COVID-19 at-home tests purchased after Jan. 15, plan members are required to file a claims with their insurance plan. The majority of the coronavirus resource websites we have seen include instructions to download and print a COVID-19 Over-the-Counter (OTC) Test Kit Claims Form.

With this current process, these reimbursements are most likely going to be painful for both the payers and their members. But, a digital forms solution – which can be implemented quickly – can make this experience much more seamless.

Filling Out the Claims Form

Current State:

Even large, national health insurers are posting claims forms that were created in Microsoft Word. While it’s impressive what a determined designer can create in Microsoft Word, a claims form shouldn’t be one of those things. These documents are clearly intended from the start to be printed and filled out with pen and paper.

It makes little sense to start with a digital Microsoft Word file saved as a Portable Document Format (PDF) that a member must access with a digital device, only to have the member print out the form and thereby convert a somewhat digital process to analog, via ink and paper. If a member needs a device to access the form, why can’t they use a device to fill it out? Even a fillable PDF form would be better for all involved, as it would at least remove legibility as a potential barrier to processing the form.

Then there is the sheer number of fields that must be considered and potentially completed on these forms – we have seen at least one claim form that had nearly 100 fields! Common form fields include requesting information about the test kit(s) purchased, primary customer, patient and coverage, as well as several attestations and a certification as to the authenticity and accuracy of the information being provided.

By our estimate, the insurer that had posted this form already has 50 to70% of this information.

Desired Future State:

Investing in digital forms transformation for COVID-19 related claims allows health insurers to easily implement an intelligent, guided experience while also connecting to systems of record to pull in existing data for the member to review and (optionally) update. The remaining required information could be reduced to a few clicks with a series of simple yes/no questions and checkboxes.

Submitting the Claims Form

Current State:

Most insurers are asking members to mail or fax the completed reimbursement form. There are three big problems with these outdated submission methods:

No confirmation for the member that the form was ever received by the insurer.
The information on the form is not secure in transit.
It creates the opportunity for the member to forget to attach the receipt.

Yes, one could pay extra to add tracking to the mailed form, however we can assume few people will go through the effort given the relatively low dollar amount of each reimbursement (up to $12 per individual test).

Some might say that a fax machine will tell the member whether the transmission was successful, and that is true. But what if the member mistakenly dialed the wrong fax number? This poses security concerns for personally identifiable and/or protected health information. What if the insurer uses a fax server? The member will never know until the reimbursement check shows up that the right department received the form. With faxing, there’s likely to be an interim step – copying the receipt onto a standard-sized sheet of paper so it will fax better. This wastes the member’s time and money and increases the risk that the receipt will not be legible. Besides, how many members in 2022 have easy access to a fax machine?

Desired Future State:

Cloud-native, digital forms solutions are accessible using any internet-connected device via a web browser. They leverage device capabilities like cameras for taking pictures of receipts, which can be attached electronically. Digitizing the end-to-end process eliminates handwriting and handling.

Processing the Claims Forms

Current State:

When relying entirely on physical forms, the chances of a large number of submissions being Not in Good Order (NIGO) are high. Potential errors or issues include a skipped a field, illegible handwriting, a forgotten receipt, a missing signature, date and more. We estimate that at least 10% of forms will be rejected for some reason other than the purchase was made prior to the start of the program.

Consider this: All the forms submitted via fax or mail will need to be (re)digitized and then run through optical character recognition (OCR) software. No OCR package claims accuracy greater than 99% on a page level (so 990 out of 1,000 characters will be correct), and that’s with typed characters; research has shown that the accuracy often drops for handwritten or photocopied material.

If the average COVID-19 test claims form has 100 fields and if the average field has five characters (FYI, the average email address is 21.9 characters long and the average last name in the U.S. is more than five characters), then at least five characters will be incorrect on every form processed. Will it be the transaction details, rendering the form useless? Will it be the member’s name, rendering the check null and void? Or will it be the mailing address, rendering the check undeliverable?

Desired Future State:

Digital forms for COVID-19 related claims allow health plans to use business logic to ensure that forms are in good order prior to a member submitting. They can integrate with e-signature solutions, thereby negating the need for printing, mailing or faxing anything to the payer. And, these solutions can generate PDF documents so the member has a record of what was submitted, and the insurer has something that can be provided to an auditor or a regulator if required.

Where to Go from Here

The implications of COVID-19 have shed a light on the need for digital forms transformation. As the course of the pandemic continues to change, so too will state and local governments, public health officials and health insurers’ responses. In such a fast-moving climate, it’s more important than ever to have sophisticated, cloud-based technologies that enable health plans to be innovative, agile and efficient.

When faced with all the areas in healthcare that are ripe for transformation, it can feel overwhelming to decide where to start. At Smart Communications, we believe in identifying certain processes that can be transformed quickly and provide near-immediate results. Investing in forms transformation is a key step in modernizing healthcare and optimizing the end-to-end member experience.

Beyond collecting information and checking boxes, redefining how information is gathered means health insurers can respond quickly and via preferred channels – a critical component of every stage within the member experience. Intelligent interviews modernize the collection and use of member information, empower members to initiate conversations with their health plans and remove friction from critical interactions.

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SmartIQ from Smart Communications is a low-code form automation and digital process software that takes manual form processes and reimagines them—turning one-way, disjointed form processes into innovative, two-way interactions that expedite processing times and create experiences customers appreciate. To learn more about how SmartIQ enhances digital forms for COVID-19 related claims, check out our ebook 5 Ways Health Insurers Can Reimagine Forms.

Digital Transformation in Healthcare Claims

Posted on December 2, 2021 by Mary Featherstone

By: John Zimmerer, VP Healthcare Marketing at Smart Communications

Digital transformation in healthcare had been moving at a steady but very slow pace for years – until the pandemic forced the industry to accelerate its digital-first initiatives. Despite the progress made in the last 18 months, the healthcare industry still has plenty of opportunity to enhance the customer experience through more digital interactions.

One critical customer journey where this is particularly evident is claims. From finding, figuring out, filling out and submitting a claim form (e.g., for an out-of-network service); to receiving an adjudication notice, navigating to and reviewing an Explanation of Benefits (EOB); to having to contact the payer to ask a question about the claim and submitting an appeal, the whole process can often feel disjointed and inefficient.

In this post, we dive into the future of digital transformation in healthcare and how payers can reimagine the claims experience.

The Current State of the Claims Journey

Often, claims are considered a cost of doing business for health insurers. As a key component of the Medical Loss Ratio (MLR), an insurer’s primary objective is usually to minimize the administration and operational expenses related to processing claims and handling appeals and grievances.

Many claim-related communications are designed from the inside out, with regulations and risk in mind rather than with an eye toward the customer experience. Once the templates are created, they tend not to be revised much unless required by rule or due to an acquisition. These communications are treated as individual point solutions managed by IT, rather than as touchpoints that connect a customer journey.

Here’s a summary of today’s typical claim-related experience:

The member, Grace, receives an email notifying her that “a claim was recently processed.” Grace wonders which claim the email is referencing.
The email directs Grace to log into her payer’s member portal to review the claim. Grace looks for a link in the email to click but doesn’t see one. She opens a browser, logs in to her payer’s member portal, and navigates to claims.
Grace deduces which claim the email was referring to. She didn’t see a visual indicator, like a “new” tag or other label, so she assumes she’s looking for the most recent claim.
Grace clicks on the claim line item to view summary information, then on the EOB to see details. The EOB is a PDF file, originally designed to be printed and mailed, not for viewing on a computer screen or a mobile device.
Grace has a question about the claim. The EOB directs her (and every other member) to call her plan’s member services department. Grace would have preferred a self-service option.
Grace tells the member services rep that takes her call that she is certain that she had already satisfied her deductible prior to the date of service in question and feels that her responsible portion should be much lower. The call center rep points Grace to a form to request a redetermination (i.e., to file an appeal) and asks Grace if there’s anything else the rep can help Grace with.
A bit frustrated that her issue hasn’t been resolved to her satisfaction, Grace says, “no,” and hangs up the phone. She starts looking for the form the rep mentioned and wonders how she’ll know the payer has received it or how long it will take before her payer begins the redetermination process.

This interaction just increased the risk that Grace will not renew her plan (i.e., churn), but her payer doesn’t know that yet.

The Desired Future State of the Claims Journey

Fortunately, there is a better way that is relatively simple to implement and will deliver immediate value. A new, orchestrated process can connect these disjointed touchpoints into a guided experience and increase member satisfaction (and NPS scores). This future state can also lower claims administration expenses, especially for individual and group plans where these costs tend to be highest.

Here’s a revised version of the scenario above:

Grace sees a new link in the EOB to ask a question. The virtual agent senses the context of the question and pulls in information related to the specific claim.
After answering a few questions, the agent prepares, and Grace reviews and submits, a request for an organizational redetermination (i.e., a Level 1 appeal). All the information required for the appeal is prepopulated which means Grace clicks more than she types.
The request creates a case for the Appeals and Grievances (AG) group to review the claim. The case includes the appeal form with the information Grace provided.
The AG employee reviews the case and creates a determination letter from within her CRM. In this case, the request is approved; however, the editing software is flexible and allows the AG employee to create different correspondence if the request is approved, denied or pending (e.g., if additional information is required).
Upon generating the correspondence, Grace is sent an email with the determination letter attached and an NPS survey in the body of the email.
The entire history of engagements and all related activity – sends, opens, clicks, etc. – is available to any payer employee authorized to access Grace’s CRM record.

This future-state scenario is achievable with The Conversation Cloud^TM from Smart Communications, including these solutions for connecting the claims experience:

SmartCOMM^TM for sending the notification, EOB and correspondence
SmartIQ^TM for the internal appeal request, consent form and NPS survey
Orchestration across all the touchpoints and channels
Integrations, e.g., with Facets for claims data and Salesforce for case management

Accelerate Digital Transformation in Healthcare Claims

Smart Communications has helped accelerate digital transformation in healthcare claims for insurers like Blue Shield of California through its ISO-certified and HIPAA-compliant Conversation Cloud platform.

Ready to enable new members to self serve and streamline claims processes to improve member experience and reduce administration costs? Watch how our solutions help organiations like yours make connected claims experiences possible.

How Re-imagining Communications Can Deepen Member Engagement for Health Insurance Carriers

Posted on July 6, 2020 by Ayla

By Brian Damiani, MBA, CHCIO, Founder and CEO, Wendigo Advisors

In my nearly twenty years working with health insurance carriers I have seen an amazing number of good things come to pass. From the increasing adoption of new technology to the adjustment to value-based reimbursements and the ACA/Medicaid expansion efforts that brought insurance to those who traditionally did not have access. This year will be no different with many companies dealing with new interoperability requirements and benefit changes related to COVID-19. Having an insider’s perspective allows me to see the good side of the health insurance market more easily than most.

However, health insurance companies continue to have some of the lowest customer satisfaction ratings of all companies in the U.S.—rivaled only by cable and internet service providers. While the health insurance industry overall needs some definite improvement there is no reason why they cannot improve relationships with their members. The problem is that the current methods of communicating with members are not effective and, in many cases, actually reinforce the negative attitude members have toward their carriers.

Take members with chronic conditions as an example. According to the CDC approximately 60% of adults in the U.S. have at least one chronic condition and this number increases with age. Additionally, more than two-thirds of deaths in the U.S. come as the result of chronic conditions such as diabetes, hypertension, and heart disease and it is estimated that 90% of the $3.5 trillion annual health care spend goes toward treating chronic conditions.

It is clearly in the best interest of health insurance carriers to work closely with members with these conditions yet members’ trust in these companies remains at all-time lows. According to a recent JD Power survey only 36% of members believe that their health insurance carrier has the members’ best interests in mind and only 25% view their plan as a trusted partner in the members’ health and wellness. This study also showed that customer satisfaction is directly linked to customer engagement. One of the key components for improving trust, and thereby health care outcomes, is member engagement. Improving how companies interact and communicate with members is key to positively affecting this dynamic.

Traditional disease management efforts by health insurance carriers tend to leverage printing and mailing educational materials to members or placing robocalls in an effort to get members engaged. These methods have resulted in very limited success. However, as new communications technologies come in to play they can, and should, be leveraged to allow members to receive communications in the most appropriate and effective way for that individual, and to allow plans to share critical health related information in a more interactive and conversational way.

Imagine if we could change the traditional, one-way, “fire and forget” communications to efficient, bi-directional, conversations between plans and members. Members would be more receptive to advice and information shared by their carrier. Carriers would be better able to communicate the benefits of programs and would get more traction on efforts to reduce things like re-admission rates and chronic disease impacts. Following up on procedures to ensure complications are caught early also becomes easier. Through these methodologies engagement, satisfaction, outcomes, and trust all increase.

So how do carriers accomplish this? They need technology solutions that not only improve conversations with members but also improve internal administrative requirements such as reducing the number of communication templates while increasing the number of communication channels available for use. Increasing the personalization of communications to members helps them feel less like a “number” and more like an important consumer of the company’s services. All of this can help in changing how members view and interact with their plan carriers.

Wendigo Advisors
Wendigo Advisors provides CIO-as-a-Service in part-time and interim roles to health plans across the US.

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1. Digital Forms Can Help Address This Customer Driver Behind CX and Loyalty

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Provide the Ultimate Healthcare Customer Experience: The Guide to Member Engagement Strategies

Changing Customer Expectations and Regulations Drive Trends in Healthcare

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Convert One-way Customer Communications to Two-way Conversations

The Conversation CloudTM for Health Insurers

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The Impact of Forms Automation on the Healthcare Customer Experience

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Contact us to request a free live demo to see how you can implement a secure and simple patient appointment system that enhances the patient experience, eliminates friction and creates better patient workflows.

Supporting the Injured Worker

Enabling Greater Efficiency for Employers

Empowering Medical Providers for Improved Care

Improving the Options for Case Managers

Driving to Digital with the Conversation Cloud

A Time for Progress

Complying with Rules and Regulations

Solutions Trusted by Leading Health Insurers

Streamline Health Insurance Policy Renewals

The Current State of the Claims Journey

The Desired Future State of the Claims Journey

Accelerate Digital Transformation in Healthcare Claims

The Conversation Cloud^TM for Health Insurers