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WHITE PAPER
CUSTOMER EXPERIENCE MEETS
THE HEALTHCARE JOURNEY
HOW TO WIN TODAY’S HEALTHCARE CUSTOMER
Executive Summary
Over the past decade multiple forces have caused the healthcare market in America
to transition from that of managed care and capitation to integrated delivery
(integration of health insurance with provider systems) to a vision in which
providers compete to improve care quality and control costs, and consumers choose
the best providers. The only thing that is likely to remain constant is change,
particularly as provisions of the Patient Protection and Affordable Care Act take
effect over the next few years aimed at improving healthcare outcomes and
streamlining the delivery of health care.
At the most fundamental level there are three perspectives on the discussion that
need to be understood and accounted for if any meaningful discussion is to be held,
here represented as the “Three Ps of Healthcare” which translates to Patient,
Provider and Payor.
FIGURE 1: THREE PS OF HEALTHCARE
Patient
ProviderPayor
TABLE OF CONTENTS
Executive Summary.................. 1
1. Task Routing and Workload
Distribution .............................. 5
2. Resource Management ...... 11
3. Facilities Management ....... 15
4. Revenue Cycle
Management.......................... 18
5. Compliance......................... 20
Summary................................ 23
Solution Components............. 24
Conclusion.............................. 24
About Genesys ....................... 24
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You can see in this diagram that there are interaction points between all three; the
triangle in the center represents offerings that are integrated. Although each have a
critical role to play in order to understand contact and medical history, the goal is to
find the right balance that delivers optimal patient health at a reasonable cost. In a
fully integrated environment – the triangle in Figure 1 – we would find a model
solution operating as one contact system that provides the following for each
stakeholder:
• Patients: Front-end solution, with the insurer or medical group, to view
claims, bills, contact history, medical history, e-mail the doctor, look-up
symptoms, and so on.
• Provider: Task Routing, facilities management, revenue cycle management.
• Payor (Insurer vs. Patient):
o Insurer: system to pull Healthcare Effectiveness Data and
Information Set (HEDIS), claims, costs reports, charts for case
management, etc.
o Patient: billing, collection, back office financials, etc.
The Centers for Medicare and Medicaid Services (CMS) and Health & Human
Services (HHS) are especially keen on this idea of making sure their money goes a
long way, and they are asking insurers and providers to integrate systems, processes
and the overall healthcare system so that focus is delivery to the patient. Their
message has always been:
Don’t make healthcare difficult for the consumer, period!
In lieu of this level of integration, the focus should be on the Provider delivery
system. One way to understand how this plays out is to examine the patient
healthcare journey.
Patient Healthcare Journey
Just as no two patients are the same, no two healthcare journeys are the same. In
order to provide some framework, consider two common scenarios. The first
scenario involves the initial task every patient has of finding and visiting a primary
care physician for Routine/Preventative care.
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FIGURE 2: ROUTINE/PREVENTATIVE CARE JOURNEY
The patient must first contact the physician referral service in order to find an
appropriate provider. Then the patient must contact the provider’s office to
schedule an appointment. After visiting the physician, the account needs to be
settled. This could be covered by insurance, in which case a co-pay will likely need
to be paid by the patient. In some situations the entire cost may be the
responsibility of the patient.
Consider the level of coordination between The Three Ps for something as simple as
a routine doctor visit. Apart from the actual visit, think of the legions of people
working behind the scenes to schedule the appointment, code services, file a claim,
determine benefit eligibility, pay the bill and keep tabs on the status!
The second scenario is for Acute/Emergency needs that involve wellness centers,
physicians, hospitals and urgent care centers for the patient. This process is more
complex as it can involve activities prior to the visit to identify financial
responsibility, and after the visit to speed recovery and minimize avoidable hospital
readmissions.
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FIGURE 3: ACUTE/EMERGENCY CARE JOURNEY
During a visit to the physician it is determined that it will be necessary to schedule a
procedure at the hospital. The provider works with the patient and the insurer to
ascertain financial responsibility. The patient visits the hospital, has the procedure
performed, and is discharged. A bill is sent to the insurer, and any unpaid balance is
billed to the patient.
And just like with the Routine/Preventative example, the Acute/Emergency
situation relies on an even greater level of coordination between The Three Ps.
There are lots of moving parts in both examples, yet each stakeholder needs to
protect their interest while providing for the patient’s optimal health. Areas in
need of examination include:
1. Task Routing and Workload Distribution
2. Resource Management
3. Facilities Management
4. Revenue Cycle Management
5. Compliance
The remainder of this document explores the Provider delivery system in greater
detail.
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1. Task Routing and Workload Distribution
Multiple interactions happen between all three parties as well as ancillary
participants and suppliers such as outpatient clinics, pharmacies and suppliers of
durable medical equipment. If the contact is not face-to-face, there's a good chance
that the interaction will be handled by a contact center, acting as the intermediary
for various business units.
FIGURE 4: PATIENT INTERACTIONS
The primary source of work in most contact centers comes from inbound voice calls
that are handled by an Automated Call Director (ACD). In some cases there may
also be outbound call activity that is either direct dial or handled by an outbound
dialer. There could also be a range of digital channels available to facilitate email,
chat, SMS and video interactions.
Sometimes the interaction is short - simply answering a question; other times, it
may be an involved process spread out over time. Regardless of the interaction
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channel used, the goal is to connect the patient with the right resource to get
information or assistance.
FIGURE 5: INTERACTION CHANNELS
Interaction Channels
Patients have become accustomed to interacting with most companies via inbound
and outbound voice for decades, as well as fax for sending and receiving printed
forms and documents. More recent digital channels include:
• E-Mail for discussing symptoms, recommending a course of action and
sending prescriptions, especially when the patient is out-of-town;
submitting electronic documents such as out-of-network claims.
• Chat and Video for interacting with nurse advice teams.
• SMS/MMS for sending appointment reminders, receiving images from
patients.
Mobile devices enable applications that blend all of the self and assisted service
functions. One key benefit of mobile apps is that they require patient
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authentication, and they can provide location-based services like finding the nearest
clinic.
Case Management systems include appointment scheduling, facilities management,
patient reminders, pharmacy services, claims processing, and business office
functions like accounts receivables.
Information areas include:
• Locations and Services
• Medical Encyclopedia
• Health Guides
• Disease and Symptom Information
• Drugs and Medicine
• Class Information and Registration
Self-Service functions include:
• Locations and Services
• Appointment scheduling and changes
• Class Information and Registration
• Prescription Refills
• Business Office
Resource targets include:
• Physician Referral
• Appointment Scheduling
• Class Information and Registration
• Pre-Clearance
• Nurse Advice
• Physician
• Pharmacy
• Business Office
Many organizations are now multi-channel in the contact center. Extending
interaction routing beyond the contact center allows you to leverage investments in
technology and improve the patient experience across the enterprise.
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Contact Center
The primary purpose of the contact center is to provide assistance to patients
needing a physician referral, scheduling appointments, claims processing, and
business office functions related to accounts receivable.
FIGURE 6: INBOUND ROUTING
Important considerations include proper identification and authentication of the
patient to maintain HIPAA compliance, and placing each interaction in context to
more completely understand the immediate patient need.
Nurse Advice
Healthcare providers offering Nurse Advice services can improve the quality of life
for their patients by making nurses available 24x7 for those situations that do not
require a visit to the doctor. When the needs go beyond allowable limits, the
nursing team can act as a conduit to the PCP, or alert ER staff about a patient on the
way. In addition, these teams may perform check-up calls on patients recently
discharged from the hospital to ensure they are following doctor’s orders, and
perform protocols related to ongoing chronic health maintenance.
In addition to inbound and outbound voice channels, Nurse Advice teams are
increasingly turning to digital channels for communication. One of the most
important advances here is in the area of video, as research indicates that patients
who can see the nurse are more inclined to follow instructions. This is especially
useful for health maintenance issues like diabetes where prevention is critical.
Physician
In the past, much of the interaction between physician and patient has been face-
to-face or over the phone. More recently, some physicians have embraced email as
an alternate form of interaction, particularly for those patients who don’t need to
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be seen in person for treatment. In addition, escalations from the Nurse Advice
team enable physicians to keep abreast of patient needs.
Workload Distribution
Healthcare providers utilize various methods of workload management today.
Some segments are automated, such as those for scheduling appointments. Others
are almost ad hoc, like the way email is processed. The goal should be to accurately
inventory all work that needs to be done at any moment in time, assign a priority,
and route to the most appropriate resource equipped with the most appropriate
tools to respond.
Each interaction type follows a standard triage process.
FIGURE 7: TRIAGE PROCESS
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Those conditions categorized as "Expectant" or "Immediate" are routed to
emergency or urgent care. Those categorized as "Delayed" or "Minor" are handled
by the primary care physician. Each interaction could further have a numeric value
attached to provide ranking within a category based on patient history and the
severity of the need. As interactions were created and categorized, the attendant
workload could be calculated. Then the interaction would be routed to the most
appropriate resource available.
FIGURE 8: TASK SOURCES
Notification to the resource could be facilitated most easily by mobile device (e.g.,
smart phone or tablet), with an option to "ignore" or "delay" response in the event
that a more pressing issue needs attention. If that were to happen, the interaction
would be re-routed to the new most appropriate resource.
Each event handled by workload management is tracked by interaction channel for
accurate classification, task duration and patient outcomes to ensure that the right
amount of time was allocated to future similar events. An accommodation could be
made for some number of "urgent, non-scheduled" events to be inserted each hour.
Most Available Resource
e-Mail
Ask-A-
Nurse
Escalation
Face-to-
Face
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All of the tasks handled by the physician are accounted for in order to provide a
more complete picture of productivity by:
• Channel:
o Face-to-Face
o Inbound/Outbound Voice
o E-mail
o Web
o Chat
o Video
• Season (cold/flu, back-to-school, etc.)
• Illness (chronic, health maintenance, etc.)
• Demographic (age, ethnicity, etc.)
Then the provider could:
• Filter, prioritize and push ‘next most important patient’ to the most
appropriate resource:
o Physician
o Physician Assistant
o Nurse
• Predict resource requirements by channel
• Forecast, schedule and track events and resources
• Link productivity to compensation
Additionally, healthcare delivery can develop pricing models based on access
channel. For patients who triage to a point where treatment options are feasible
without seeing the doctor, plans could offer lower cost of access. These usually
allow some number of escalations per year at no charge; then a fee for low-cost
plans that exceed triage limits.
2. Resource Management
Our research has found that for every front office worker there are three knowledge
workers in the back office providing support. It can be quite a challenge for
operations leaders to manage back office workers in the same way that they have
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grown accustomed to for agents in the contact center, largely because much of
what goes on in the back office involves manual tasks that are off the radar.
Along the same lines, managing resources that historically engaged with patients
face-to-face is equally challenging. The engagement models are notoriously difficult
to expand to non-real-time tasks like e-mail, even though the medical services
rendered are no less important. However, recent developments now make it
possible to identify back office and off-queue tasks and route just like a call. This
capability is especially interesting in multi-channel environments where resources
have blended skills.
Advanced workforce management tools make it possible for staff planners to juggle
all of the activity that occurs on voice and non-voice channels, allowing resources to
seamlessly move between tasks and channels throughout the day. These same
capabilities have been extended beyond the contact center to work-at-home
agents, nurses and physicians in order to optimize service and minimize costs.
Tools
In order for this to work properly, a range of performance management tools are
needed to understand what is happening in real-time as well as from a historical
perspective. Additional tools are needed to calculate workload, identify needed
skills and training requirements, and manage the workforce performing the tasks.
FIGURE 9: SUPPORTING ELEMENTS
PERFORMANCE MANAGEMENT
The reporting tools used for performance management present information in
historical and real-time format for all resources involved in direct patient
interactions, regardless of location.
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FIGURE 10: PERFORMANCE MANAGEMENT
Beyond the contact center, reporting tools also consider patient interactions
handled in clinics and hospitals for phone, e-mail, Web, chat, SMS, video and work
items. The information possibilities are endless, but include:
• Interactions by: channel, patient, facility
• Duration of interactions and end-to-end processes
• Outcomes
• Trends
• Patient Satisfaction
All are critical for sustainability and long-term growth.
WORKFORCE OPTIMIZATION
Regardless of staff location or interaction channel, workforce optimization tools aim
to forecast, schedule and track activities. In the contact center this is most often
driven by inbound and outbound call activity handled by the phone system. But as
outlined here, off-queue activities are equally important. The real challenge comes
in when patients use multiple channels to engage, and when staff are capable of
accepting work from all of the channels used by the patient.
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FIGURE 11: WORKFORCE OPTIMIZATION
Where all tasks (calls, e-mail, face-to-face appointments, etc.) are handled by a
single routing platform, this makes it easy to:
• Calculate staff utilization by channel.
• Forecast staffing needs by channel, season, illness, demographic, etc.
• Tie productivity to compensation.
This becomes especially important in determining compensation rates for highly
paid staff interacting with patients across multiple channels throughout the day.
Some providers are considering compensation models that differentiate between
interaction types, volume, response time and outcomes to reward top performers.
The idea is to encourage doctors to meet with patients for more than a few minutes
during an office visit and to also compensate them, or nurse coordinators, for
communicating with patients by phone and e-mail even when it may be outside of
normal office hours. Doctors would also be compensated for helping patients
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manage chronic conditions - like reminding diabetic people to take their insulin--
and would be encouraged to transmit prescriptions electronically.
3. Facilities Management
Hospitals make money when beds are occupied. This poses at least two big
challenges to hospital administrators: managing the pipeline to achieve optimal
occupancy levels while reducing avoidable hospital readmissions.
Pipeline Control
The first issue involves real-time knowledge of beds available, as well as those likely
to become available within the next 24-hours. One way to accomplish this is to
understand all of the events linked to discharge, and ensure they are actioned in a
timely manner.
FIGURE 12: DISCHARGE PROCEDURE
Even when the answer to any decision point is “yes,” there must be a link to the
related activity to ensure the ultimate goal of ‘discharge’ for the patient. For
example, it’s one thing to ask “is transport available” to take the patient home or to
an outpatient care facility; it’s quite another to know that the transportation has
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been scheduled. If the transportation fails to show up on time, the patient cannot
be discharged and the bed will thus not be available for the next patient.
FIGURE 13: TASK DETAIL
Each of these decision points will likely spawn a series of activities involving multiple
entities as well as the patient and their family. The only way to ensure that each
stakeholder is aware of their responsibility is to utilize a workload distribution
system – the same system described earlier in Section 1 for tracking, prioritizing and
routing tasks or work items.
FIGURE 14: WORKLOAD DISTRIBUTION
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Readmissions
Approximately three-quarters of hospitalized patients are able to return to their
home environment following discharge. However, among Medicare patients,
almost 20 percent who are discharged from a hospital are readmitted within 30
days. This represents a significant risk for hospitals, who now have a financial
motivation to cut readmissions as Medicare recently began penalizing those with
higher-than-expected rates of readmission within 30 days of patients' original stay.
There are many contributing factors to avoidable hospital readmissions, including
the effectiveness of the discharge process outlined above, and effective monitoring
of the patient after discharge. Specific insurance benefits and availability of
services in the community may also influence whether or not the patient may be
safely discharged home.
Along the same lines as managing discharge planning, proper patient care after
discharge can dramatically reduce the odds of readmission. Proper scheduling and
monitoring of home services, such as visiting nurses or infusion providers to
administer intravenous infusions, may allow selected patients, who would otherwise
need non-acute residential care, to manage their transitional care needs at home.
FIGURE 15: POST DISCHARGE TASKS
For discharge home, patients, with help from family or other caregivers if available,
should be able to:
• Obtain and self-administer medications
• Perform self-care activities
• Eat an appropriate diet or otherwise manage nutritional needs
• Follow-up with designated providers
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If discharge to the outpatient setting is not appropriate, the discharge team must
arrange transfer to another inpatient facility for ongoing care. Determining the
most appropriate inpatient setting of care for ongoing treatment involves
determining the patient's needs and matching needs with the capabilities of
potential sites of care.
As with Pipeline Control, the only way to ensure that each stakeholder is aware of
their responsibility after the patient has been discharged is to utilize a workload
distribution system – the same system described earlier in Section 1 for tracking,
prioritizing and routing tasks or work items. Service Level Agreements (SLAs) need
to be established at each juncture to measure performance against the goal of
minimizing readmissions.
SLA management will in turn shape operational procedures. For example,
scheduling and making regular outbound calls to determine if the patient is taking
the proper amount of medication at the right time, performing self-care, eating
properly and following up with providers. Failure to aggressively do this on
schedule greatly increases the likelihood of an avoidable readmission. SLA
monitoring will feed the closed-loop process improvement, and provide early
warning of patients at high risk of readmission.
4. Revenue Cycle Management
Like all businesses, hospitals need to be paid for services rendered. Many patients
provide a co-pay and rely on some form of insurance to pay for medical needs. In
some situations the patient is uninsured, or seeks services that are not covered by
their plan. When that happens, the patient has a financial obligation that must be
met.
Healthcare providers can create strategies to improve debt collection cycles by
setting the right expectations up front, confirming benefit eligibility and account
responsibilities before any services are rendered. Presuming accurate charges have
been captured and coded, timely claim submission is critical to reimbursement.
For unpaid balances, additional work is needed. This includes proactively reminding
patients that payment is due in a few days, highlighting patients who have a high
probability of missing payments, and improving patient loyalty by shaping payment
behaviors through regular communication.
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FIGURE 16: REVENUE CYCLE MANAGEMENT
Patients are diverse and pretty clever when it comes to avoiding calls from
collections. They are pretty adept at using caller ID, call blocking and voicemail.
They also change mobile phone numbers easily and frequently. This makes them
more difficult to contact with a much higher contact failure rate.
But compensating for this is the bigger range of communication means now
available. Some debtors may be easier to reach in the morning rather than the
afternoon or may answer their mobile phone in preference to their home phone.
All this information can be used to customize the treatment of specific contacts. As
well as home phones, work phones and mobile phones, debtors can now be
contacted by e-mail and SMS as well. All of these channels can be used as a means
of improving contact, taking into account regional compliance rules.
Using an outbound dialer allows healthcare providers to operate more efficiently.
They can decide when to use live agents for calls that require the unique skills of a
live agent. Or, they can determine which contacts should be made without an agent
pre-recorded voice messages for things like payment reminders, e-mail or SMS.
Other efficiencies can be achieved by call blending in the contact center. Blending
uses outbound/blended agents to smooth out inbound calling peaks during high
traffic times. When these peaks return to normal call volumes, the blended agent
resume outbound calling. Outbound is all about achieving more productivity and
greater efficiencies.
Collections Strategy
Creative and innovative strategies can optimize collection success and/or enhance
patient relationships, while keeping costs to a minimum.
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• Reach the responsible party as early as possible after their account becomes
delinquent in order to present the widest range of options.
• Reach out to the responsible party even before they are in trouble,
particularly those who are uninsured and pay for services with credit cards.
A single missed payment on the credit card can dramatically increase the
interest rate on the unpaid balance, thereby reducing the likelihood of
timely payment. That starts a domino effect, and all creditors are at risk.
• Segment responsible parties based on collection effort, and design
campaign strategies tailored to the unique requirements of each group.
5. Compliance
Healthcare is quite possibly the most regulated industry of all, regardless of
location. Although there are many angles on compliance, the focus here is on two
areas:
1. Task Validation.
2. Medical Loss Ratios (MLRs).
Task Validation
Many of the processes used in the Provider delivery system have actions that are
regulated. For example, HIPAA requires authentication prior to release of sensitive
patient information.
Failure to follow regulations could lead to fines and penalties – at
the time of failure, or for the lack of proof during an audit.
We actually observe the following behaviors and conditions in many healthcare
environments:
• Prioritization of tasks including compliance steps
are self-selected by employees. They decide what
tasks are important, or what order tasks should
be accomplished.
• Employees may mark a compliance task as
complete, but actually don’t do the task.
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• The fail to update the system so the audit trail is lost.
• While workflow systems are wonderful at HOW something should be done,
they fail to identify WHO is the best skilled person to perform a task.
• Managers have little insight to what tasks have been completed, or if they
have been completed in the right order.
Instead, avoid problems and the resulting fines by addressing how employees
engage with regulated work items to:
• Prove that tasks were actioned and provide an audit trail
• Prioritize, assign and push tasks to the most appropriately skilled and
available employee
• Optimize resource utilization to control costs
There are four main components required to make this work:
1. Task Validation proves that a task was auctioned and provides an audit trail.
It does this by controlling and tagging all of the interactions patients have
with you – inbound and outbound. The tags are the links that allow tracing
so that you can prove things actually happened.
2. Prioritization and Push of tasks to employees based on regulatory
requirements, business rules, SLAs and employee skill.
3. Employee Process Improvement provides reporting tools to provide insight
into performance, task completion and workload. Knowing what happened
is important; using that information to continually improve what you are
doing is critical.
4. Resource Optimization to forecast, train, schedule and track all resources
for activities.
For patient interactions using inbound/outbound voice it may also be advisable to
apply business rules that would identify call types or segments that are subject to
compliance, and configure the rules to trigger the call recording platform. This
could be done for patient authentication, authorizing surrogate decision-makers,
confirming acknowledgment of transfer to a wellness center and so on.
Taken together, these manage the risk and cost associated with Task Validation.
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Medical Loss Ratios (MLRs)
The Affordable Care Act requires health insurance issuers to submit data on the
proportion of premium revenues spent on clinical services and quality
improvement, also known as the Medical Loss Ratio (MLR). It also requires them to
issue rebates to enrollees if this percentage does not meet minimum standards.
MLR requires insurance companies to spend at least 80% or 85% of premium dollars
on medical care, with the review provisions imposing tighter limits on health
insurance rate increases. If they fail to meet these standards, the insurance
companies will be required to provide a rebate to their customers starting in 2012.
Insurance companies that issue policies to individuals, small employers, and large
employers will have to report the following information in each State it does
business:
• Total earned premiums;
• Total reimbursement for clinical services;
• Total spending on activities to improve
quality; and
• Total spending on all other non-claims
costs excluding federal and State taxes
and fees.
The regulation imposes civil monetary penalties if an insurer fails to comply with the
reporting and rebate requirements set forth in the regulation. Although the law
allows HHS to develop separate monetary penalties for medical loss ratio non-
compliance, HHS has adopted the HIPAA penalties in this regulation. The
regulation’s penalty for each violation is $100 per entity, per day, per individual
affected by the violation.
CONSIDERATIONS
There are at least two key things healthcare insurance companies need to focus on
for MLR compliance:
1. Accurate and timely reporting to HHS.
2. Identification of the types of “activities to improve quality” and amount
spent.
Following NAIC recommendations, this regulation specifies a comprehensive set of
“quality improving activities” that allows for future innovations and may be counted
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toward the 80 or 85 percent standard. Quality improving activities must be
grounded in evidence-based practices, take into account the specific needs of
patients and be designed to increase the likelihood of desired health outcomes in
ways that can be objectively measured.
In order to maintain incentives for innovation, insurers will not be required to
present initial evidence in order to designate an activity as “quality improving” when
they first begin implementing it. However, to ensure value, the insurer will have to
show measurable results stemming from the quality improvement activity in order
to continue claiming that it does in fact improve quality.
On further examination, it may be possible to attribute some of the technology
overhead costs to the 85% side of the equation as “quality improving activities”
instead of the 15% side for overhead. For example, integrated providers may be
able to implement technology on the delivery side that could be leveraged by the
insurance side at minimal cost.
Alternatively, insurers may need to more closely examine CAPEX v. OPEX models for
technology, or consider moving technology responsibilities to a wholly-owned
subsidiary.
Summary
This document has provided a closer examination of five key areas in the Provider
delivery system:
1. Task Routing and Workload Distribution
2. Resource Management
3. Facilities Management
4. Revenue Cycle Management
5. Compliance
Taken together, all of these work together to deliver optimal results for the Three Ps
of Healthcare – Patient, Provider and Payor. Integration of key systems and
comprehensive analytical tools are essential for understanding and managing the
patient experience end-to-end. This includes streamlining operational throughput,
controlling costs and ensuring compliance.
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Solution Components
Genesys Customer Interaction Management (CIM) platform is the framework used
for routing and reporting on customer interactions.
Genesys Workload Management consists of four main components:
• intelligent Workload Distribution (iWD) - Supports customer service
delivery beyond the contact center by tracking, prioritizing and routing tasks
or work items.
• Workforce Optimization - Reduces staffing costs, improves productivity and
protects service levels with accurate forecasting and scheduling for all
interaction channels.
• Skills Management - Proactively assesses and maintains employee skills so
they have the right skill sets to handle work streams across all interaction
channels.
• Interactive Insights – Historical reporting that delivers a complete picture of
employee performance and work streams across multiple operations and
channels.
These components work together to provide visibility to all patient interactions,
which can then be tracked and used for forecasting and scheduling resources.
Genesys Quality Management software gives you the three tools you’ll need to
help you meet your customer service objectives: Call Recording, Quality Manager
and Screen Capture.
Conclusion
If a healthcare delivery organization has a contact center in place for physician
referrals, appointment scheduling, pre-clearance, business office and accounts
receivable, they are likely to utilize multi-channel, utilizing inbound/outbound voice,
e-Mail and chat. Extending the contact center infrastructure to the providers will
deliver similar benefits and higher cost savings to the enterprise.
About Genesys
Genesys is driven by our cause to save the world from bad customer service. We do
it by applying a relentless focus on the consumer perspective of the customer
experience — and the impact it has on your business. Genesys works with its
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customers and partners world-wide to deliver the experience that today’s digital
consumers want. It all adds up to one seamless customer conversation.
Great customer service extends beyond the contact center to the processes and
work streams involved in meeting your commitments. Genesys products give you
insight into and control over these processes, so you can truly track the customer
experience from end to end.
Corporate Headquarters
Genesys
2001 Junipero Serra Blvd.
Daly City, CA 94014
USA
Worldwide Inquiries:
Tel: +1 650 466 1100
Fax: +1 650 466 1260
E-mail: info@genesyslab.com
www.genesyslab.com
Genesys is a leading provider of contact center and customer service software — with more than 2,200 customers in
80 countries. With over 20 years of contact center innovation and experience, Genesys software directs more than
100 million interactions every day, maximizing the value of customer engagement and differentiating the experience
by driving personalization and multichannel customer service — as well as extending customer service across the
enterprise to optimize processes and the performance of customer-facing employees.
For more information visit: www.genesyslab.com, or call +1 888 GENESYS.
Genesys and the Genesys logo are registered trademarks of Genesys Telecommunications Laboratories, Inc. All other
company names and logos may be trademarks or registered trademarks of their respective holders. © 2013 Genesys
Telecommunications Laboratories, Inc. All rights reserved.

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Win Healthcare Customers with a Seamless Journey

  • 1. WHITE PAPER CUSTOMER EXPERIENCE MEETS THE HEALTHCARE JOURNEY HOW TO WIN TODAY’S HEALTHCARE CUSTOMER Executive Summary Over the past decade multiple forces have caused the healthcare market in America to transition from that of managed care and capitation to integrated delivery (integration of health insurance with provider systems) to a vision in which providers compete to improve care quality and control costs, and consumers choose the best providers. The only thing that is likely to remain constant is change, particularly as provisions of the Patient Protection and Affordable Care Act take effect over the next few years aimed at improving healthcare outcomes and streamlining the delivery of health care. At the most fundamental level there are three perspectives on the discussion that need to be understood and accounted for if any meaningful discussion is to be held, here represented as the “Three Ps of Healthcare” which translates to Patient, Provider and Payor. FIGURE 1: THREE PS OF HEALTHCARE Patient ProviderPayor TABLE OF CONTENTS Executive Summary.................. 1 1. Task Routing and Workload Distribution .............................. 5 2. Resource Management ...... 11 3. Facilities Management ....... 15 4. Revenue Cycle Management.......................... 18 5. Compliance......................... 20 Summary................................ 23 Solution Components............. 24 Conclusion.............................. 24 About Genesys ....................... 24
  • 2. Customer Experience Meets the Healthcare Journey / Page 2 of 25 WHITE PAPER WHITE PAPER You can see in this diagram that there are interaction points between all three; the triangle in the center represents offerings that are integrated. Although each have a critical role to play in order to understand contact and medical history, the goal is to find the right balance that delivers optimal patient health at a reasonable cost. In a fully integrated environment – the triangle in Figure 1 – we would find a model solution operating as one contact system that provides the following for each stakeholder: • Patients: Front-end solution, with the insurer or medical group, to view claims, bills, contact history, medical history, e-mail the doctor, look-up symptoms, and so on. • Provider: Task Routing, facilities management, revenue cycle management. • Payor (Insurer vs. Patient): o Insurer: system to pull Healthcare Effectiveness Data and Information Set (HEDIS), claims, costs reports, charts for case management, etc. o Patient: billing, collection, back office financials, etc. The Centers for Medicare and Medicaid Services (CMS) and Health & Human Services (HHS) are especially keen on this idea of making sure their money goes a long way, and they are asking insurers and providers to integrate systems, processes and the overall healthcare system so that focus is delivery to the patient. Their message has always been: Don’t make healthcare difficult for the consumer, period! In lieu of this level of integration, the focus should be on the Provider delivery system. One way to understand how this plays out is to examine the patient healthcare journey. Patient Healthcare Journey Just as no two patients are the same, no two healthcare journeys are the same. In order to provide some framework, consider two common scenarios. The first scenario involves the initial task every patient has of finding and visiting a primary care physician for Routine/Preventative care.
  • 3. Customer Experience Meets the Healthcare Journey / Page 3 of 25 WHITE PAPER WHITE PAPER FIGURE 2: ROUTINE/PREVENTATIVE CARE JOURNEY The patient must first contact the physician referral service in order to find an appropriate provider. Then the patient must contact the provider’s office to schedule an appointment. After visiting the physician, the account needs to be settled. This could be covered by insurance, in which case a co-pay will likely need to be paid by the patient. In some situations the entire cost may be the responsibility of the patient. Consider the level of coordination between The Three Ps for something as simple as a routine doctor visit. Apart from the actual visit, think of the legions of people working behind the scenes to schedule the appointment, code services, file a claim, determine benefit eligibility, pay the bill and keep tabs on the status! The second scenario is for Acute/Emergency needs that involve wellness centers, physicians, hospitals and urgent care centers for the patient. This process is more complex as it can involve activities prior to the visit to identify financial responsibility, and after the visit to speed recovery and minimize avoidable hospital readmissions.
  • 4. Customer Experience Meets the Healthcare Journey / Page 4 of 25 WHITE PAPER WHITE PAPER FIGURE 3: ACUTE/EMERGENCY CARE JOURNEY During a visit to the physician it is determined that it will be necessary to schedule a procedure at the hospital. The provider works with the patient and the insurer to ascertain financial responsibility. The patient visits the hospital, has the procedure performed, and is discharged. A bill is sent to the insurer, and any unpaid balance is billed to the patient. And just like with the Routine/Preventative example, the Acute/Emergency situation relies on an even greater level of coordination between The Three Ps. There are lots of moving parts in both examples, yet each stakeholder needs to protect their interest while providing for the patient’s optimal health. Areas in need of examination include: 1. Task Routing and Workload Distribution 2. Resource Management 3. Facilities Management 4. Revenue Cycle Management 5. Compliance The remainder of this document explores the Provider delivery system in greater detail.
  • 5. Customer Experience Meets the Healthcare Journey / Page 5 of 25 WHITE PAPER WHITE PAPER 1. Task Routing and Workload Distribution Multiple interactions happen between all three parties as well as ancillary participants and suppliers such as outpatient clinics, pharmacies and suppliers of durable medical equipment. If the contact is not face-to-face, there's a good chance that the interaction will be handled by a contact center, acting as the intermediary for various business units. FIGURE 4: PATIENT INTERACTIONS The primary source of work in most contact centers comes from inbound voice calls that are handled by an Automated Call Director (ACD). In some cases there may also be outbound call activity that is either direct dial or handled by an outbound dialer. There could also be a range of digital channels available to facilitate email, chat, SMS and video interactions. Sometimes the interaction is short - simply answering a question; other times, it may be an involved process spread out over time. Regardless of the interaction
  • 6. Customer Experience Meets the Healthcare Journey / Page 6 of 25 WHITE PAPER WHITE PAPER channel used, the goal is to connect the patient with the right resource to get information or assistance. FIGURE 5: INTERACTION CHANNELS Interaction Channels Patients have become accustomed to interacting with most companies via inbound and outbound voice for decades, as well as fax for sending and receiving printed forms and documents. More recent digital channels include: • E-Mail for discussing symptoms, recommending a course of action and sending prescriptions, especially when the patient is out-of-town; submitting electronic documents such as out-of-network claims. • Chat and Video for interacting with nurse advice teams. • SMS/MMS for sending appointment reminders, receiving images from patients. Mobile devices enable applications that blend all of the self and assisted service functions. One key benefit of mobile apps is that they require patient
  • 7. Customer Experience Meets the Healthcare Journey / Page 7 of 25 WHITE PAPER WHITE PAPER authentication, and they can provide location-based services like finding the nearest clinic. Case Management systems include appointment scheduling, facilities management, patient reminders, pharmacy services, claims processing, and business office functions like accounts receivables. Information areas include: • Locations and Services • Medical Encyclopedia • Health Guides • Disease and Symptom Information • Drugs and Medicine • Class Information and Registration Self-Service functions include: • Locations and Services • Appointment scheduling and changes • Class Information and Registration • Prescription Refills • Business Office Resource targets include: • Physician Referral • Appointment Scheduling • Class Information and Registration • Pre-Clearance • Nurse Advice • Physician • Pharmacy • Business Office Many organizations are now multi-channel in the contact center. Extending interaction routing beyond the contact center allows you to leverage investments in technology and improve the patient experience across the enterprise.
  • 8. Customer Experience Meets the Healthcare Journey / Page 8 of 25 WHITE PAPER WHITE PAPER Contact Center The primary purpose of the contact center is to provide assistance to patients needing a physician referral, scheduling appointments, claims processing, and business office functions related to accounts receivable. FIGURE 6: INBOUND ROUTING Important considerations include proper identification and authentication of the patient to maintain HIPAA compliance, and placing each interaction in context to more completely understand the immediate patient need. Nurse Advice Healthcare providers offering Nurse Advice services can improve the quality of life for their patients by making nurses available 24x7 for those situations that do not require a visit to the doctor. When the needs go beyond allowable limits, the nursing team can act as a conduit to the PCP, or alert ER staff about a patient on the way. In addition, these teams may perform check-up calls on patients recently discharged from the hospital to ensure they are following doctor’s orders, and perform protocols related to ongoing chronic health maintenance. In addition to inbound and outbound voice channels, Nurse Advice teams are increasingly turning to digital channels for communication. One of the most important advances here is in the area of video, as research indicates that patients who can see the nurse are more inclined to follow instructions. This is especially useful for health maintenance issues like diabetes where prevention is critical. Physician In the past, much of the interaction between physician and patient has been face- to-face or over the phone. More recently, some physicians have embraced email as an alternate form of interaction, particularly for those patients who don’t need to
  • 9. Customer Experience Meets the Healthcare Journey / Page 9 of 25 WHITE PAPER WHITE PAPER be seen in person for treatment. In addition, escalations from the Nurse Advice team enable physicians to keep abreast of patient needs. Workload Distribution Healthcare providers utilize various methods of workload management today. Some segments are automated, such as those for scheduling appointments. Others are almost ad hoc, like the way email is processed. The goal should be to accurately inventory all work that needs to be done at any moment in time, assign a priority, and route to the most appropriate resource equipped with the most appropriate tools to respond. Each interaction type follows a standard triage process. FIGURE 7: TRIAGE PROCESS
  • 10. Customer Experience Meets the Healthcare Journey / Page 10 of 25 WHITE PAPER WHITE PAPER Those conditions categorized as "Expectant" or "Immediate" are routed to emergency or urgent care. Those categorized as "Delayed" or "Minor" are handled by the primary care physician. Each interaction could further have a numeric value attached to provide ranking within a category based on patient history and the severity of the need. As interactions were created and categorized, the attendant workload could be calculated. Then the interaction would be routed to the most appropriate resource available. FIGURE 8: TASK SOURCES Notification to the resource could be facilitated most easily by mobile device (e.g., smart phone or tablet), with an option to "ignore" or "delay" response in the event that a more pressing issue needs attention. If that were to happen, the interaction would be re-routed to the new most appropriate resource. Each event handled by workload management is tracked by interaction channel for accurate classification, task duration and patient outcomes to ensure that the right amount of time was allocated to future similar events. An accommodation could be made for some number of "urgent, non-scheduled" events to be inserted each hour. Most Available Resource e-Mail Ask-A- Nurse Escalation Face-to- Face
  • 11. Customer Experience Meets the Healthcare Journey / Page 11 of 25 WHITE PAPER WHITE PAPER All of the tasks handled by the physician are accounted for in order to provide a more complete picture of productivity by: • Channel: o Face-to-Face o Inbound/Outbound Voice o E-mail o Web o Chat o Video • Season (cold/flu, back-to-school, etc.) • Illness (chronic, health maintenance, etc.) • Demographic (age, ethnicity, etc.) Then the provider could: • Filter, prioritize and push ‘next most important patient’ to the most appropriate resource: o Physician o Physician Assistant o Nurse • Predict resource requirements by channel • Forecast, schedule and track events and resources • Link productivity to compensation Additionally, healthcare delivery can develop pricing models based on access channel. For patients who triage to a point where treatment options are feasible without seeing the doctor, plans could offer lower cost of access. These usually allow some number of escalations per year at no charge; then a fee for low-cost plans that exceed triage limits. 2. Resource Management Our research has found that for every front office worker there are three knowledge workers in the back office providing support. It can be quite a challenge for operations leaders to manage back office workers in the same way that they have
  • 12. Customer Experience Meets the Healthcare Journey / Page 12 of 25 WHITE PAPER WHITE PAPER grown accustomed to for agents in the contact center, largely because much of what goes on in the back office involves manual tasks that are off the radar. Along the same lines, managing resources that historically engaged with patients face-to-face is equally challenging. The engagement models are notoriously difficult to expand to non-real-time tasks like e-mail, even though the medical services rendered are no less important. However, recent developments now make it possible to identify back office and off-queue tasks and route just like a call. This capability is especially interesting in multi-channel environments where resources have blended skills. Advanced workforce management tools make it possible for staff planners to juggle all of the activity that occurs on voice and non-voice channels, allowing resources to seamlessly move between tasks and channels throughout the day. These same capabilities have been extended beyond the contact center to work-at-home agents, nurses and physicians in order to optimize service and minimize costs. Tools In order for this to work properly, a range of performance management tools are needed to understand what is happening in real-time as well as from a historical perspective. Additional tools are needed to calculate workload, identify needed skills and training requirements, and manage the workforce performing the tasks. FIGURE 9: SUPPORTING ELEMENTS PERFORMANCE MANAGEMENT The reporting tools used for performance management present information in historical and real-time format for all resources involved in direct patient interactions, regardless of location.
  • 13. Customer Experience Meets the Healthcare Journey / Page 13 of 25 WHITE PAPER WHITE PAPER FIGURE 10: PERFORMANCE MANAGEMENT Beyond the contact center, reporting tools also consider patient interactions handled in clinics and hospitals for phone, e-mail, Web, chat, SMS, video and work items. The information possibilities are endless, but include: • Interactions by: channel, patient, facility • Duration of interactions and end-to-end processes • Outcomes • Trends • Patient Satisfaction All are critical for sustainability and long-term growth. WORKFORCE OPTIMIZATION Regardless of staff location or interaction channel, workforce optimization tools aim to forecast, schedule and track activities. In the contact center this is most often driven by inbound and outbound call activity handled by the phone system. But as outlined here, off-queue activities are equally important. The real challenge comes in when patients use multiple channels to engage, and when staff are capable of accepting work from all of the channels used by the patient.
  • 14. Customer Experience Meets the Healthcare Journey / Page 14 of 25 WHITE PAPER WHITE PAPER FIGURE 11: WORKFORCE OPTIMIZATION Where all tasks (calls, e-mail, face-to-face appointments, etc.) are handled by a single routing platform, this makes it easy to: • Calculate staff utilization by channel. • Forecast staffing needs by channel, season, illness, demographic, etc. • Tie productivity to compensation. This becomes especially important in determining compensation rates for highly paid staff interacting with patients across multiple channels throughout the day. Some providers are considering compensation models that differentiate between interaction types, volume, response time and outcomes to reward top performers. The idea is to encourage doctors to meet with patients for more than a few minutes during an office visit and to also compensate them, or nurse coordinators, for communicating with patients by phone and e-mail even when it may be outside of normal office hours. Doctors would also be compensated for helping patients
  • 15. Customer Experience Meets the Healthcare Journey / Page 15 of 25 WHITE PAPER WHITE PAPER manage chronic conditions - like reminding diabetic people to take their insulin-- and would be encouraged to transmit prescriptions electronically. 3. Facilities Management Hospitals make money when beds are occupied. This poses at least two big challenges to hospital administrators: managing the pipeline to achieve optimal occupancy levels while reducing avoidable hospital readmissions. Pipeline Control The first issue involves real-time knowledge of beds available, as well as those likely to become available within the next 24-hours. One way to accomplish this is to understand all of the events linked to discharge, and ensure they are actioned in a timely manner. FIGURE 12: DISCHARGE PROCEDURE Even when the answer to any decision point is “yes,” there must be a link to the related activity to ensure the ultimate goal of ‘discharge’ for the patient. For example, it’s one thing to ask “is transport available” to take the patient home or to an outpatient care facility; it’s quite another to know that the transportation has
  • 16. Customer Experience Meets the Healthcare Journey / Page 16 of 25 WHITE PAPER WHITE PAPER been scheduled. If the transportation fails to show up on time, the patient cannot be discharged and the bed will thus not be available for the next patient. FIGURE 13: TASK DETAIL Each of these decision points will likely spawn a series of activities involving multiple entities as well as the patient and their family. The only way to ensure that each stakeholder is aware of their responsibility is to utilize a workload distribution system – the same system described earlier in Section 1 for tracking, prioritizing and routing tasks or work items. FIGURE 14: WORKLOAD DISTRIBUTION
  • 17. Customer Experience Meets the Healthcare Journey / Page 17 of 25 WHITE PAPER WHITE PAPER Readmissions Approximately three-quarters of hospitalized patients are able to return to their home environment following discharge. However, among Medicare patients, almost 20 percent who are discharged from a hospital are readmitted within 30 days. This represents a significant risk for hospitals, who now have a financial motivation to cut readmissions as Medicare recently began penalizing those with higher-than-expected rates of readmission within 30 days of patients' original stay. There are many contributing factors to avoidable hospital readmissions, including the effectiveness of the discharge process outlined above, and effective monitoring of the patient after discharge. Specific insurance benefits and availability of services in the community may also influence whether or not the patient may be safely discharged home. Along the same lines as managing discharge planning, proper patient care after discharge can dramatically reduce the odds of readmission. Proper scheduling and monitoring of home services, such as visiting nurses or infusion providers to administer intravenous infusions, may allow selected patients, who would otherwise need non-acute residential care, to manage their transitional care needs at home. FIGURE 15: POST DISCHARGE TASKS For discharge home, patients, with help from family or other caregivers if available, should be able to: • Obtain and self-administer medications • Perform self-care activities • Eat an appropriate diet or otherwise manage nutritional needs • Follow-up with designated providers
  • 18. Customer Experience Meets the Healthcare Journey / Page 18 of 25 WHITE PAPER WHITE PAPER If discharge to the outpatient setting is not appropriate, the discharge team must arrange transfer to another inpatient facility for ongoing care. Determining the most appropriate inpatient setting of care for ongoing treatment involves determining the patient's needs and matching needs with the capabilities of potential sites of care. As with Pipeline Control, the only way to ensure that each stakeholder is aware of their responsibility after the patient has been discharged is to utilize a workload distribution system – the same system described earlier in Section 1 for tracking, prioritizing and routing tasks or work items. Service Level Agreements (SLAs) need to be established at each juncture to measure performance against the goal of minimizing readmissions. SLA management will in turn shape operational procedures. For example, scheduling and making regular outbound calls to determine if the patient is taking the proper amount of medication at the right time, performing self-care, eating properly and following up with providers. Failure to aggressively do this on schedule greatly increases the likelihood of an avoidable readmission. SLA monitoring will feed the closed-loop process improvement, and provide early warning of patients at high risk of readmission. 4. Revenue Cycle Management Like all businesses, hospitals need to be paid for services rendered. Many patients provide a co-pay and rely on some form of insurance to pay for medical needs. In some situations the patient is uninsured, or seeks services that are not covered by their plan. When that happens, the patient has a financial obligation that must be met. Healthcare providers can create strategies to improve debt collection cycles by setting the right expectations up front, confirming benefit eligibility and account responsibilities before any services are rendered. Presuming accurate charges have been captured and coded, timely claim submission is critical to reimbursement. For unpaid balances, additional work is needed. This includes proactively reminding patients that payment is due in a few days, highlighting patients who have a high probability of missing payments, and improving patient loyalty by shaping payment behaviors through regular communication.
  • 19. Customer Experience Meets the Healthcare Journey / Page 19 of 25 WHITE PAPER WHITE PAPER FIGURE 16: REVENUE CYCLE MANAGEMENT Patients are diverse and pretty clever when it comes to avoiding calls from collections. They are pretty adept at using caller ID, call blocking and voicemail. They also change mobile phone numbers easily and frequently. This makes them more difficult to contact with a much higher contact failure rate. But compensating for this is the bigger range of communication means now available. Some debtors may be easier to reach in the morning rather than the afternoon or may answer their mobile phone in preference to their home phone. All this information can be used to customize the treatment of specific contacts. As well as home phones, work phones and mobile phones, debtors can now be contacted by e-mail and SMS as well. All of these channels can be used as a means of improving contact, taking into account regional compliance rules. Using an outbound dialer allows healthcare providers to operate more efficiently. They can decide when to use live agents for calls that require the unique skills of a live agent. Or, they can determine which contacts should be made without an agent pre-recorded voice messages for things like payment reminders, e-mail or SMS. Other efficiencies can be achieved by call blending in the contact center. Blending uses outbound/blended agents to smooth out inbound calling peaks during high traffic times. When these peaks return to normal call volumes, the blended agent resume outbound calling. Outbound is all about achieving more productivity and greater efficiencies. Collections Strategy Creative and innovative strategies can optimize collection success and/or enhance patient relationships, while keeping costs to a minimum.
  • 20. Customer Experience Meets the Healthcare Journey / Page 20 of 25 WHITE PAPER WHITE PAPER • Reach the responsible party as early as possible after their account becomes delinquent in order to present the widest range of options. • Reach out to the responsible party even before they are in trouble, particularly those who are uninsured and pay for services with credit cards. A single missed payment on the credit card can dramatically increase the interest rate on the unpaid balance, thereby reducing the likelihood of timely payment. That starts a domino effect, and all creditors are at risk. • Segment responsible parties based on collection effort, and design campaign strategies tailored to the unique requirements of each group. 5. Compliance Healthcare is quite possibly the most regulated industry of all, regardless of location. Although there are many angles on compliance, the focus here is on two areas: 1. Task Validation. 2. Medical Loss Ratios (MLRs). Task Validation Many of the processes used in the Provider delivery system have actions that are regulated. For example, HIPAA requires authentication prior to release of sensitive patient information. Failure to follow regulations could lead to fines and penalties – at the time of failure, or for the lack of proof during an audit. We actually observe the following behaviors and conditions in many healthcare environments: • Prioritization of tasks including compliance steps are self-selected by employees. They decide what tasks are important, or what order tasks should be accomplished. • Employees may mark a compliance task as complete, but actually don’t do the task.
  • 21. Customer Experience Meets the Healthcare Journey / Page 21 of 25 WHITE PAPER WHITE PAPER • The fail to update the system so the audit trail is lost. • While workflow systems are wonderful at HOW something should be done, they fail to identify WHO is the best skilled person to perform a task. • Managers have little insight to what tasks have been completed, or if they have been completed in the right order. Instead, avoid problems and the resulting fines by addressing how employees engage with regulated work items to: • Prove that tasks were actioned and provide an audit trail • Prioritize, assign and push tasks to the most appropriately skilled and available employee • Optimize resource utilization to control costs There are four main components required to make this work: 1. Task Validation proves that a task was auctioned and provides an audit trail. It does this by controlling and tagging all of the interactions patients have with you – inbound and outbound. The tags are the links that allow tracing so that you can prove things actually happened. 2. Prioritization and Push of tasks to employees based on regulatory requirements, business rules, SLAs and employee skill. 3. Employee Process Improvement provides reporting tools to provide insight into performance, task completion and workload. Knowing what happened is important; using that information to continually improve what you are doing is critical. 4. Resource Optimization to forecast, train, schedule and track all resources for activities. For patient interactions using inbound/outbound voice it may also be advisable to apply business rules that would identify call types or segments that are subject to compliance, and configure the rules to trigger the call recording platform. This could be done for patient authentication, authorizing surrogate decision-makers, confirming acknowledgment of transfer to a wellness center and so on. Taken together, these manage the risk and cost associated with Task Validation.
  • 22. Customer Experience Meets the Healthcare Journey / Page 22 of 25 WHITE PAPER WHITE PAPER Medical Loss Ratios (MLRs) The Affordable Care Act requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the review provisions imposing tighter limits on health insurance rate increases. If they fail to meet these standards, the insurance companies will be required to provide a rebate to their customers starting in 2012. Insurance companies that issue policies to individuals, small employers, and large employers will have to report the following information in each State it does business: • Total earned premiums; • Total reimbursement for clinical services; • Total spending on activities to improve quality; and • Total spending on all other non-claims costs excluding federal and State taxes and fees. The regulation imposes civil monetary penalties if an insurer fails to comply with the reporting and rebate requirements set forth in the regulation. Although the law allows HHS to develop separate monetary penalties for medical loss ratio non- compliance, HHS has adopted the HIPAA penalties in this regulation. The regulation’s penalty for each violation is $100 per entity, per day, per individual affected by the violation. CONSIDERATIONS There are at least two key things healthcare insurance companies need to focus on for MLR compliance: 1. Accurate and timely reporting to HHS. 2. Identification of the types of “activities to improve quality” and amount spent. Following NAIC recommendations, this regulation specifies a comprehensive set of “quality improving activities” that allows for future innovations and may be counted
  • 23. Customer Experience Meets the Healthcare Journey / Page 23 of 25 WHITE PAPER WHITE PAPER toward the 80 or 85 percent standard. Quality improving activities must be grounded in evidence-based practices, take into account the specific needs of patients and be designed to increase the likelihood of desired health outcomes in ways that can be objectively measured. In order to maintain incentives for innovation, insurers will not be required to present initial evidence in order to designate an activity as “quality improving” when they first begin implementing it. However, to ensure value, the insurer will have to show measurable results stemming from the quality improvement activity in order to continue claiming that it does in fact improve quality. On further examination, it may be possible to attribute some of the technology overhead costs to the 85% side of the equation as “quality improving activities” instead of the 15% side for overhead. For example, integrated providers may be able to implement technology on the delivery side that could be leveraged by the insurance side at minimal cost. Alternatively, insurers may need to more closely examine CAPEX v. OPEX models for technology, or consider moving technology responsibilities to a wholly-owned subsidiary. Summary This document has provided a closer examination of five key areas in the Provider delivery system: 1. Task Routing and Workload Distribution 2. Resource Management 3. Facilities Management 4. Revenue Cycle Management 5. Compliance Taken together, all of these work together to deliver optimal results for the Three Ps of Healthcare – Patient, Provider and Payor. Integration of key systems and comprehensive analytical tools are essential for understanding and managing the patient experience end-to-end. This includes streamlining operational throughput, controlling costs and ensuring compliance.
  • 24. Customer Experience Meets the Healthcare Journey / Page 24 of 25 WHITE PAPER WHITE PAPER Solution Components Genesys Customer Interaction Management (CIM) platform is the framework used for routing and reporting on customer interactions. Genesys Workload Management consists of four main components: • intelligent Workload Distribution (iWD) - Supports customer service delivery beyond the contact center by tracking, prioritizing and routing tasks or work items. • Workforce Optimization - Reduces staffing costs, improves productivity and protects service levels with accurate forecasting and scheduling for all interaction channels. • Skills Management - Proactively assesses and maintains employee skills so they have the right skill sets to handle work streams across all interaction channels. • Interactive Insights – Historical reporting that delivers a complete picture of employee performance and work streams across multiple operations and channels. These components work together to provide visibility to all patient interactions, which can then be tracked and used for forecasting and scheduling resources. Genesys Quality Management software gives you the three tools you’ll need to help you meet your customer service objectives: Call Recording, Quality Manager and Screen Capture. Conclusion If a healthcare delivery organization has a contact center in place for physician referrals, appointment scheduling, pre-clearance, business office and accounts receivable, they are likely to utilize multi-channel, utilizing inbound/outbound voice, e-Mail and chat. Extending the contact center infrastructure to the providers will deliver similar benefits and higher cost savings to the enterprise. About Genesys Genesys is driven by our cause to save the world from bad customer service. We do it by applying a relentless focus on the consumer perspective of the customer experience — and the impact it has on your business. Genesys works with its
  • 25. Customer Experience Meets the Healthcare Journey / Page 25 of 25 WHITE PAPER WHITE PAPER customers and partners world-wide to deliver the experience that today’s digital consumers want. It all adds up to one seamless customer conversation. Great customer service extends beyond the contact center to the processes and work streams involved in meeting your commitments. Genesys products give you insight into and control over these processes, so you can truly track the customer experience from end to end. Corporate Headquarters Genesys 2001 Junipero Serra Blvd. Daly City, CA 94014 USA Worldwide Inquiries: Tel: +1 650 466 1100 Fax: +1 650 466 1260 E-mail: info@genesyslab.com www.genesyslab.com Genesys is a leading provider of contact center and customer service software — with more than 2,200 customers in 80 countries. With over 20 years of contact center innovation and experience, Genesys software directs more than 100 million interactions every day, maximizing the value of customer engagement and differentiating the experience by driving personalization and multichannel customer service — as well as extending customer service across the enterprise to optimize processes and the performance of customer-facing employees. For more information visit: www.genesyslab.com, or call +1 888 GENESYS. Genesys and the Genesys logo are registered trademarks of Genesys Telecommunications Laboratories, Inc. All other company names and logos may be trademarks or registered trademarks of their respective holders. © 2013 Genesys Telecommunications Laboratories, Inc. All rights reserved.