Member Experience: Never a Better Time for Digital Enablement



November 23, 2020

Health plans are all too familiar with the challenges of member experience—that perfect storm of call/processing volume surge, staffing challenges, and critical moment-of-truth engagement pressures. And the stakes are even higher for 2021, according to JD Power research.  The organization’s fourth annual study found that member satisfaction averages dropped from 712 on a 1,000-point scale in 2009 to 701 in 2020. J.D. Power and Associates measures health plan satisfaction of 133 health plans in 17 U.S. regions in seven areas: coverage and benefits, provider choice, information and communication, claims processing, statements, customer service, and approval process.

To be successful, today’s digital-led member engagement must meet the needs of Generation “C” – the “connected” customer demographic that spans generations. These consumers make purchasing decisions based on brand reputation and a more personalized experience. A strong digital toolkit, containing interaction analytics; AI-powered data capture; and automation, will elevate and customize engagement to earn and retain these buyers. It may be counterintuitive, but digital enablers such as analytics, AI-powered intake, and bots can deliver a more empathetic, customized member enrollment experience—one that earns and retains customers for life.


Interaction Analytics solutions offer key advantages along all consumer journey touchpoints, delivering essential ROI with voice of consumer insights related to preferences and experience enhancements to drive higher CSAT and NPS. Contact centers have a goldmine of customer feedback.Insights can be built from speech data that is a valuable information source of customer sentiment and intent. The data tells the unbiased story here – to avoid missed opportunities or misalignment of feedback. The proactive insights built at the crucial open enrollment phase are actionable by helping health plans to tailor their product development to consumer choice across key member demographics.

Case example: As a value-added service, Sagility engaged with a leading health insurer client to implement VOC analytics. Our solution was deployed to transcribe and analyze millions of interactions. We conducted a deep-dive analysis on negative customer feedback into how claims settlements are made and the customers’ lack of awareness of the benefits provided by new insurance products, especially in the Open Enrollment season. The results included:

  • Better correlation between NPS/CSAT rating and call types, driving a solid 33%​ NPS and CSAT improvement.
  • A more streamlined and frictionless claims settlement process along with more frequent and clearly defined communication to all customers regarding insurance products and their benefits.
  • A trend analysis of member demographics by geography, resulting in better provider network relations.

AI-powered data capture

Today’s cutting-edge machine learning, optical character recognition (OCR), and intelligent character recognition (ICR) for cognitive intake have elevated the document management process once considered highly burdensome for payers. The open enrollment process is a touchpoint ideally suited to intelligent data capture. Open enrollment is a highly paper-intensive process that presents an excellent opportunity for improvement. With the inherent paperwork and processing, AI-powered innovation provides tremendous opportunity for workflow enhancements to minimize subjectivity of structured/unstructured data—for faster turnaround and cost savings.

Case Example: Sagility created an intelligent machine learning solution to help improve a client’s Star rating—a measure directly linked to member experience. The team addressed the entire workflow with a cognitive content processing solution leveraging an image analytics engine to process the source. The solution featured a natural language processing (NLP) engine to analyze key words and context. For one process, this as-a-service solution drove Star ratings improvement of the MA plan by an 8% weighted average. For member experience, this data capture closes the loop, addressing member resolutions via AI for quick, accurate decision making—those functions on which Star ratings are established. With better ratings, step one of the member experience journey—plan selection—is enhanced.


By bringing greater automation to the open enrollment process, organizations can decrease their labor requirements while realizing a greater return on investment. Bots can streamline the repetitive and time-consuming steps of the open enrollment process for crucial desktop efficiencies that significantly impact customer experience. This “straight-through processing” is the smartest path of least resistance, with a bot-brain approach to address seasonal challenges with intelligence.

Case Example: For a leading health plan, Sagility looked at a process of manual data entry for member details in the enrollment system, starting from intake applications over different formats. For Specialty enrollment, as per this process, the client was converting XML into PDF applications, which were manually indexed and given to resources for entry. Before Sagility’s involvement, there were 12 screens to be filled manually, with requirements of more than 99% accuracy for data entry. For Medical enrollment, applications were coming from brokers with multiple instances of missed information and multiple data entry provisions. Sagility leveraged blended RPA solutions to take Specialty and Medical queues live. For Specialty, we helped drive an increase from 25 to 40 apps daily, reducing costs by 40%. For Medical, we reduced costs by 30%, decreasing the time taken to complete one application by five hours. With these processes, the Sagility achieved $400,000 in annual savings for the client.

The above case examples are proof points to support the fact that BPO partners bring a unique solution mix to address open enrollment: automation and analytics as-a-service capabilities, seasonal talent scale and agility, and right-shoring cost savings. The right BPOs are ideally suited to accommodate needs like open enrollment on the principles of lean operations, and also co-creation, design thinking, and globalization. Beyond cost-cutting, good BPOs implement meaningful changes that help eliminate silos and align objectives in order to achieve true operational and engagement impact.