How A Data Strategy Improves Health Insurance Member Satisfaction


Medicare Advantage Star Ratings play a key role in enrollment volume. Studies have found that for plans with a rating of 3 stars or less, a 1-star improvement could lead to an 8% to 12% enrollment increase. With the Centers for Medicaid and Medicare (CMS) recently adjusting its star ratings to weigh member experience measures more heavily, it’s even more important that health insurers examine member processes and data.

For many insurers, that means a lot of disparate data points are spread across multiple systems. Member chat data may be in your chat app. Member call data in your voice system. Interactions with your website may be in another system. Claims data is in yet another system. Having member data spread across multiple systems makes it difficult to see the big picture. As a result, you aren’t maximizing your member experience.

Creating a coherent member data strategy can help. Here’s an example of how a data strategy improves health insurance member satisfaction:

Member Experience Journey

First, start by mapping your member experience journey. For example, say a member experiences back pain. In a typical workflow, the member might visit their doctor who prescribes drugs to treat the pain. It doesn’t improve, and the member visits an emergency room. Give his history of back pain, he eventually talks to a surgeon about surgical procedures. He has the surgery and goes to an out-of-network physical therapist post-surgery based on the surgeon’s recommendation.

That experience likely is high cost and low satisfaction for the member. Emergency room and out-of-network physical therapy costs are expensive. Plus, it likely took a significant amount of time — from the doctor to the emergency room to waiting for surgery to waiting to heal before seeing a therapist— to treat the back pain. Plus, they probably could have tried other, less invasive treatments that may have solved the issue.

Using Data to Improve the Member Experience

This is where a data-infused member experience can pay dividends. For example, using artificial intelligence to perform a claim review may have predicted that the member’s back pain would worsen after the doctor’s visit. That prediction could automatically start a workflow that sends the member information about therapies for the pain as well as the nearest urgent care facility should the pain worsen. Instead of an emergency room, the member instead goes to urgent care. Instead of surgery, self-care exercises are recommended, which aligns with the therapy information recently sent.

The member then accesses a chatbot to find exercises he can use. More automated analytics flag the member for a call to discuss potential therapies, like a steroid injection. The member goes to his doctor’s office, where it’s less expensive, to get a steroid injection. The injection reduces pain, which enables the member to start physical therapy, which helps solve the chronic back pain.

You can see how this data-centric approach better serves the member, reducing costs and likely leading to higher member satisfaction scores. But it can only be achieved by mapping common member journeys to try to identify where data can enhance the member experience. A good place to start would be by examining interactions or treatments that commonly lead to lower satisfaction scores from your members.

Three Simple Metrics to Capture

It’s also important that you infuse customer survey data into that member journey.  Here are some metrics to include in your data strategy that improves health insurance member satisfaction:


  1. Simple satisfaction data — After treatments or interactions with your team, ask for simple satisfaction data. Have members rate the interaction or their satisfaction with their treatment. That will give you data you can leverage to find low-ranked treatments or interactions and identify ways to improve them. A simple “How happy were you with X” question asking to rate an experience on a 1 to 5 scale can help.
  2. Ease of use — Your goal should be to reduce as much friction as possible when members receive care or access your resources. In the back pain example above, your process included proactively reaching out to members to recommend treatments and solutions. Though a member may be satisfied with a treatment or an interaction, capturing ease of use data may pinpoint where processes can be simplified or improved.
  3. Net Promoter Score — At least once a year, ask your members whether they’d recommend you to a peer or friend. That question forms the basis for a Net Promoter Score (NPS). That score is used by organizations across industries to compare their customer satisfaction. The NPS tells you whether you have more promoters (members who rate you a 9 or 10 on a 10-point score) or detractors (those who rate you lower than 7 on a 10-point recommendation scale). Then, you can leverage that data to create plans to help improve your relationship with detractors, maintain your promoters and hopefully transition more members to promoters.

Software Solutions

Here are some solutions that can help you measure, engage and improve your member experience:

  1. Castlight- Castlight helps members navigate health care by delivering tools that help payers connect members with the right programs and care at the right time. Learn more at
  1. Optum Performance Insights — Optum Performance Insights helps payers leverage analytics to reduce variation, improve care quality, optimize care coordination and manage financial performance. You can learn more at
  1. Accolade — Accolade offers personalized advocacy solutions for member health needs. You can learn more at
  1. Health Advocate — Health Advocate offers several tools and solutions that make it easier to navigate healthcare decisions. You can learn more at

Certifi’s health insurance premium billing and payment solutions help healthcare payers improve member satisfaction while reducing administrative costs.


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