Success Stories › South African-Based Health Insurer

Operational Assessment that led to Marketing and Sales Analysis

The Assignment:

This health plan focuses on the Consumer Directed Healthcare market, with a particular emphasis on engaging the consumer to obtain efficient care while simultaneously rewarding them for healthy behaviors. Their systems, processes and client interactions have evolved over the last several years, with its business model, and the client asked us to validate that current practices were still market competitive and occurring in the most efficient and customer centric way possible.

Our Approach:

We began the assignment by focusing on three areas critical to any CDH plan: the claims processing center, billing processes and methodology, and the customer/relationship service model. As we got into the data, we very quickly realized that the insurer was experiencing an unusually high volume of non-electronic claims relative to industry standard.

Our interaction with the customer teams and call center groups made us aware of unusually high levels of customer dissatisfaction with claim handling. Counter to the popular assumption that the call center needed additional training, we developed a hypothesis that that the root cause of the phone calls was an upstream problem — inadequate marketing materials.

The Results:

We advised the client that paper claim submissions were negatively impacting the client on three levels:
Time added to the turn-around process to manually get the claim through the adjudicating engine.
Errors created by transcribing the information.
Inconsistent processing of like claims.

Our hypothesis about the root cause problem within the call center proved to be correct— through our audit of all customer touch points, we found that the marketing materials were far too basic and insufficient to educate members about CDHP. Rather than invest money in retraining the call center, we recommended to the client that they make some very specific changes to their materials.