Mergers in the health care industry in recent years have led companies, challenged by the doubling of membership in some cases, to find ways to blend technology and service as they relate to customer service.
Consolidation has seen Aetna Inc. acquire U.S. Healthcare, Coventry Corp. merge with Principal, Pacificare Health Systems Inc. acquire FHP, and American Medical Security Inc. merge with United Wisconsin Services Inc. Because of increased numbers of customers, AMS and Pacificare have stepped up the use of teleservices programs; Aetna and Coventry declined to talk about how they are addressing the issues.
AMS, which specializes in individual and small company coverage through a network of authorized physicians and hospitals, makes extensive use of teleservices programs through its Nurse HealthLine. The 24-hour-a-day, seven-day-a-week call center is staffed not by phone agents, as in other healthcare companies, but by 23 registered nurses with five years of clinical experience. They handle about 120,000 calls annually.
“Some of our primary objectives are to asses those who call in with physical symptoms,” said Suzanne Schroder-Johnson, director of Nurse HealthLine Inc. “We try to determine how urgent it is or whether it can wait until morning. That is our primary purpose; we try to address timeliness. Our next objective is the appropriateness of a family practitioner or primary care physician. If someone needs a referral or specialist we try to steer them to the network provider that provides the best cost benefit.”
But the service also aims to take implement proactive steps.
“Our third objective is to teach and to educate in order to increase medical knowledge,” she said.
The company maintains a nationwide, toll-free number to the company's Green Bay, WI, headquarters, which houses the call center. Nurses maintain and update patient profiles with each in-bound phone call through the use of clinical assessment software.
“We can toggle into the whole insurance business and find out by ZIP code where to send the insured.”
The center maintains an eight-second answer time for patients and adheres to follow-up calls to patients within 24-hours of their call. Separately, the company also operates an out-bound service to chronic disease patients.
“Our company prides itself on being ethical and in providing compassionate managed care,” said company spokesman, Roger Dier. “Nurse HealthLine and our disease management are just two of the ways we practice what we preach.”
In California, Pacificare's acquisition of FHP in February spurred the expansion of its call centers from three to six and doubled membership from 2 million to 4 million. Pacificare operates throughout Arizona, Texas and California; its two primary service divisions annually handle 200,000 calls each.
“For the five months until the acquisition was approved nothing changed,” said company spokeswoman Cheryl Brady. “Once the transaction was finalized we consolidated systems and created greater efficiencies and retained a lot of our employees to support new membership.”
The company operates its standard medical services programs as well as a seniors-based program, Secure Horizons, which now includes FHP's seniors program. The merger prompted a retraining for all call center agents to standardize operations.
“Secure Horizons is typically patients who are 65 years old, plus,” Brady said. “Sometimes those calls take a little longer, so agents were trained similarly to be more sensitive to talking with seniors.”
Pacificare operates a variety of 800 numbers, depending on patient population within a certain geographical area. While most 800 numbers remained the same for a bulk of its customers, northern California residents who had been covered by FHP received a new number.
“When we finalized the acquisition we sent new members identification cards and letters tailored to their specific coverage,” Brady said. “In northern California we retained an FHP call center and informed Pacificare members of the new 800 number. We looked at both operations to see what would be the easiest and most seamless for members.
“When went through the acquisition we looked at both systems and realized Pacificare had a better system,” she said. “So we converted all FHP members to Pacificare That process was done very efficiently; we had a 97.5 percent conversion to our system and services and we tried to make it as seamless as possible.”
Industrywide customer service efforts-whether or not born out of necessity–are being scrutinized by a third-party consumer watch group, the National Committee for Quality Assurance.
The organization is gearing up for final comments throughout the next month on the 1999 Managed Care Organization Accreditation Standards, which establishes a performance-based review of coverage and service of health plans. Dubbed “Accreditation '99,” the standards aim to impact a number of healthcare teleservices initiatives as they relate to information systems, follow-up programs and access to services. These are expected to be released in August.
“There are a couple of different ways we want to make sure health plans are doing good service,” said Brian Schilling, a spokesman with NCQA. “We want to make sure companies are providing good services as well as good coverage. From the member services side, for instance, we are trying to make sure people have access to member services representatives that speak the same language. Companies would be doing their members a real disservice if all representatives spoke English and didn't speak Spanish. Our guideline is that if 10 percent of a population speaks another language, a company needs to have 10 percent of its service representatives speak the same language.”