Payors / member experience
Fix It Before They Call
Every repeat call and grievance is a member telling you what to fix. Ana joins them to the claims behind them, finds the pattern early, and routes each fix to the team that owns it — so the next member never has to call.
Fixed scope: last year’s calls, grievances and claims, run inside your cloud.
Handle the Call, or Remove the Reason for It
- Each call handled, and the next one just like it
- Calls, grievances and claims sit in three systems
- CAHPS says what went wrong a year after it did
- Outreach goes to everyone, or no one
- The pattern behind the calls found and fixed at its source
- Every call and grievance joined to the member and the claim
- The experience measured as it happens, this month
- Outreach to the few who need it, with what to fix
Every Call, Grievance and Claim, One Member at a Time
A call about a bill is rarely about the bill. Ana joins the call log, grievances, claims and eligibility to the member behind them, so the pattern shows up while it’s one member — not a CAHPS score a year later.
- Calls, grievances and claims resolved to one member
- Read in place from the systems you already run
- Every question and answer logged, PHI never leaves
Why did member M-40418 call twice in April?
A denied MRI claim nobody closed. Both calls were about the bill it created.
- 04/02claim clm-5518 denied · no prior auth
- 04/05call · billing question · 14 min
- 04/12call · same claim · transferred twice
- 04/19grievance filed · billing
The Members on Their Way Out, Named
The same path, across every member: a denied claim, two calls, a grievance. Members on it leave at three times the usual rate. Ana finds them every week and ranks them by what’s at stake before the enrollment window opens.
- The path found across every member, every week
- Ranked by premium at stake and days to the window
- Each member arrives with the calls and claim behind them
Who is on the denied-claim path this month?
2,340 members, leaving at 3.1× the usual rate.
- all members 4.2%
- denied claim 1.4× all members 6.0%
- + two calls 2.2× all members 9.4%
- + grievance 3.1× all members 13.0%
Fix the Reason, Not Just the Member
Outreach saves one member; fixing the cause saves the next thousand. Ana sends the cohort to retention with the reason attached, and the pattern to the team that owns it — claims, the call center, the portal.
- Cohorts sent to retention with the reason attached
- The cause routed to the team that owns it
- Disenrollment on the path tracked month over month
What would stop this happening again?
Route billing calls about a denial to claims, and close them in one touch.
- retention 410 members before the window, reason attached
- claims ops 38% of billing calls start with a denial
- portal EOB status requests, made self-serve
- cx Disenrollment on the path, tracked weekly
Find What to Fix
Bring last year’s calls, grievances and claims. We join them inside your cloud and hand your CX and retention teams the patterns behind the calls — and who to reach first.
- 01A 30-minute call to pick the lines of business and the sources
- 02We connect inside your cloud under a BAA — nothing leaves your environment
- 03Your retention and CX teams work the cohort with us
Where Member Experience Starts
- 01 Disenrollment risk
Find the members on a path that ends in leaving — denied claims, repeat calls, grievances — and rank them by what’s at stake before the enrollment window.
- 02 Grievance and appeal drivers
Trace every grievance category back to the claims and calls behind it, and see which ones start with the same event.
- 03 Call deflection
Find the calls the portal or an ID-card reprint could have answered, and the members who make them most.
- 04 CAHPS and Stars experience measures
Watch the experiences that drive survey scores — getting care quickly, claims handled — as they happen, not a year later.
- 05 Complaint tracking for Medicare Advantage
Join CTM complaints to the member’s claims and calls, so each one arrives with its cause and its history.
- 06 New-member onboarding
See who hasn’t found a PCP, used their card or reached the portal in their first 90 days, and reach them first.
Read access, inside your environment, to last year’s call log, grievances, claims and enrollment. Your team picks the lines of business; we join them and walk retention and CX through the members on their way out.