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A large managed care health plan
In the highly regulated managed care environment health plans were required to resolve member complaints within 30 days. Although the health plan was in compliance with the 30-day requirement, there was increasing dissatisfaction with the complaint resolution process from both health plan members and contracted providers. Members were unhappy because proposed solutions took so long, and providers were unhappy because those solutions were developed unilaterally.
A project team composed of health plan members and representatives from a large contracted provider was convened to address the challenge of improving satisfaction with the complaint management process. It was discovered that the provider was typically unaware of a member complaint during a period when medical records were obtained and reviewed by the health plan.
The ability to promptly address member complaints depended on improved communication and collaboration between the health plan and contracted provider. This could be readily accomplished by establishing key contacts who would make complaint resolution a priority.
By reframing the complaint resolution process from a regulatory requirement to a mutually beneficial customer service process, the team moved the average turnaround for complaint resolution from 30 days to less than one day, with the vast majority of complaints resolved in one hour. Member and provider satisfaction with the process was greatly enhanced.
