“Be a tree.” We did a lot of improv as part of our Theater Arts curriculum. For scenes, our acting teachers would whisper an objective into our ears. These objectives were designed to create conflict or comedy, or both.
Improvisation can be both scary and fun because you never know what’s going to happen next in a scene. The players can create twists and turns in the narrative to keep the other actors on their toes, but for many actors, this exercise is not always easy.
The Meritage Medical Network Customer Service team, is made up of expert improvisers. They answer the phone all day long, not knowing who is on the other end, or what a member’s particular, problem might be, until they pick up the phone. Once they pick up a call, they launch into action, pulling up member profiles, tax IDs of providers, permissions of who they can speak to about what, procedure referrals, provider referrals, authorizations and a whole slew of other things, but they don’t know the issue they’ll be addressing until they pick up the phone. Once they do, they listen intently, and start clicking away on their keyboards with Olympic speed, opening the individual’s appropriate resources, navigating to the necessary screens that their data lives in and, there, they begin to problem solve.
After sitting with different members of our Customer Service team, I saw that the chief skills of the customer service role were steadiness, caring, listening and resourcefulness, though of course each member has their unique way of communicating.
The Customer Service team has certain work flow processes in place to make your experience the best possible one. They strive to pick up your call within 30 seconds of the phone ringing and stick with you until there is a resolution or a clear next step. Then they document everything you discussed so that if you call back, any member of the team will be able to pick up where the other left off.
I was recently at a meeting where we were trying to understand how younger people choose their health care provider. One answer was: I just go with the provider selected for me from the health plan I’m on, another was, I selected mine online. We asked questions about things like asking a friend or colleague who they liked or went to. The one universal thing that came out of this discussion was, “I’m fine with doing the online thing but what I just can’t stand is getting sent to the dreaded phone tree, that never seems to end.”
Nobody wants to call in and get an automated response that then takes you to another automated response, which then puts you on hold, and asks you to press 1 for this, and 2 for that and so on. We’re human and no matter how much technology has taken over our lives, we still very much appreciate talking to another human. Sprinkle in some thoughtful consideration of my problem and approaches on how to solve it and do it within 72 hours and you had me at, what’s your name?
Our team’s philosophy is, “just because something works, doesn’t mean it can’t be improved.” With that, they have an impressive stats board analyzing things like commercial claims turnaround by health plan, total number of abandoned calls, percent of incoming abandoned calls, average number of calls answered a day, average number of tickets created each month, average number of tickets created per call. They have a list of reasons for calls, as well as the totals and percentages for each reason, so they know where they stand with authorizations, claims, eligibility, IT requests, member and provider relations, and can more easily decipher which areas need improvement.
I was amazed to discover that our Customer Service Department has only been in effect since November of 2017. Prior to that, Customer Service and Claims were one department–Claims Customer Service. Due to recognition by a chief member of our staff that these departments would work more effectively in tandem, Customer Service and Claims became their own entities.
Creating two unique departments that allowed for Claims’ Examiners to be assigned to particular specialties, was a valuable refinement. It made sense for them to have their own work flow and to keep their own stats and analysis, so if there was a repetition of issues, problems or concerns, the pattern could be more precisely identified and communicated around. They now work not only in tandem with Customer Service, but also with our Network Relations department, who can go out to the provider offices to identify the pattern of issues that arise. So, even though we’ve been around for over 25 years, we continue to improvise, based on need. I think of our interweaving departments kind of like a jazz quartet. Players play solos which they need to make up on the spot, which requires considerable skill. Jazz is also very rhythmic, has a forward momentum, and there is actually something called “call and response” patterns in jazz in which one instrument, voice, or part of the band answers another. Customer Service, Claims, Utilization and Network Relations all have overlapping call and response. Not unlike Jazz musicians they each place a high value on finding their own sound and style.
In Utilization: Our team is primarily focused on authorizations. They check on patient’s health plan statuses and each of our Case Managers on our review team has a different health plan that they work with. The details of which doctor is making the request, where the service is being done, what the diagnostic code is, what the CPT code is for the procedure, are all critical. They include the global days and the dates of service and have a methodology in place so that each doctor and their office is kept in the loop, on all of these factors. They know the ins and outs of your particular case and they direct your information to your specific Case Manager—our utilization teams have your back!
Authorizations are the link to Claims with our UM/UR team doing the forensics. I think of our Claims specialists as investigative reporters; barreling into their complex screen of tax IDs, specialties, clinical codes and decoding them to make sure that every claim that comes through is taken care of. Accurate reports are referenced to mitigate any conflicts that arise. If there is an issue, it is then matched against the data they are seeing. Claim by claim, they comb through each detail to determine what should be paid, what obstacles are keeping them from being paid and exactly when they can be paid, all within the 45-day parameter until Check Run day. Check run day is when they send the final list out to finance so those claims get paid.
I can’t help but return to the theater analogy–the lights, the sets, the costumes, because one mistake can throw the whole ensemble off, that’s actually what often makes improv so funny. Each of our departments work together and in tandem, but are wholly unified to address all aspects of your health care—each team and their actions, critical to the next.
Sometimes it’s not a song, or a costume, or the set or the lights, but the truly hard work, behind the scenes, of understanding what people need and helping them to get it that can make such a huge difference. Sometimes you have to improvise, and sometimes you have to be a bit of a detective and sometimes it’s both and more. In shadowing our teams, I was happy to discover their considerable skills in these areas and I wondered what other kinds of feats they accomplished on a daily basis when I wasn’t watching.“Be a tree”—beautiful, strong, fruitful, resourceful. Claim: An assertion of the truth of something, typically one that is disputed or in doubt.
If a claim really is as its definition suggests, well, these are mine.
