Medicare and Medicare Advantage (MA) are complicated and complex systems to navigate, for both members and organizations. And in the age of innovative health tech, they need to identify ways to listen to members and act with a data-backed strategy to help improve member satisfaction (and Star Ratings). The stakes are high in health and more so in a competitive arena, such as Medicare, on a rolling annual basis that must provide value for members.
Without insights into how members feel, speak, and maneuver their health plan options, insurers will fail to gain an edge in competition. AI and machine learning lessen the weight of analysis and evaluation for Medicare Advantage companies through the power of conversations.
Medicare is a standardized federal health insurance plan designed for individuals aged 65 and above who meet specific program criteria. This plan remains consistent across all states and offers stability and uniformity.
Medicare Advantage (MA) plans extend coverage beyond that of traditional Medicare and hold significant value in the retirement planning of many individuals. These plans typically include the same coverage as original Medicare and may provide additional benefits such as dental, vision, and hearing coverage.
The Medicare Stars (Star Ratings) program was established by the Centers for Medicare & Medicaid Services (CMS) to assess the quality of plan coverage offered by private providers participating in Medicare Advantage, with a particular emphasis on customer experience. Plans are evaluated on a scale of 1-5 stars, with a 5-star rating signifying the highest quality standards that directly incentivize these providers by enhancing their revenue potential. Ratings are determined by distinct measures across several categories, encompassing areas such as Staying Healthy, Managing Chronic Conditions, Member Experience, Member Complaints, Customer Service, and Drug Plan goals.
Uncovering Advantages Beneath Star Ratings
The Star Ratings system incentivizes higher-performing plans, and those that achieve four or more stars are eligible for annual bonus payments from the CMS. The bonus amount increases with the plan’s rating, and these ratings are released annually. One such notable use case in which Star Ratings can affect Medicare operations is the 2023 Aetna National PPO plan with CVS Health, dropping to 3.5 Stars from 4.5, affecting their budget by nearly $800M.
During the open enrollment period (OEP/AEP), from October to December, Medicare administrators face the responsibility of educating both eligible and current beneficiaries about the diverse coverage plans and benefit options available to them. This battles against the weight carried by insurance organizations to carefully develop strategies aimed at increasing membership and maintaining financial stability year over year.
One of the largest benefits of leveraging AI in Medicare Advantage plans is the ability to be proactive. With each new year, Star Ratings affect operations and decision-making for how plans will be valued. With a platform that can ingest AEP data year over year and member feedback in real-time to pull out key topics and trends found in the member experience, the more likely leaders can proactively address and prevent member needs to rise above competing plans and, ultimately, improve Star Ratings for the new year. If MA companies are not investing in what members are telling them, they are missing out on the opportunity to improve their annual enrollment, as well as their continued operations and core efficiencies as a plan.
“It became really clear to me through the work of running Medicare Advantage plans that the need to understand, as a business, what those patients’ needs were was going to make every difference…”
Amy Brown, Founder & cEO | Authenticx
Star Ratings are not the end-all-be-all for healthcare insurers. They do not apply to every situation in the member experience, providing a limited perspective of the journey members are on. For example, look at 2024’s Star Ratings miscalculation fiasco, causing a reanalysis of scores given and an update to CMS’s process, too. This shows there are more ways to improve.
The Advantage of Listening to Conversations
The desire for insurance leaders to have a through-line in their data increases each year when they receive scores differently and with different meanings. This commonly creates additional administrative burdens for all departments – from operations and experience to marketing and compliance. How can health plans listen to their members in full when they are trying to balance action needed from a solicited scoring process?
The power lies in conversations. And listening to these member conversations at scale with the innovation of AI and machine learning models to improve the member experience to meet business objectives.
According to ActualMeds CEO and co-founder Patricia Meisner for Fierce Healthcare, this means:
- Listening to recognize and address social determinants of health (SDOH)
- Using predictive data insights to judge the likelihood of member churn
- Automating the process so attention can be driven by member engagement and care
Making Advantages from Experiences
It is these kinds of system gaps in care and innovative opportunities that Authenticx Founder & CEO Amy Brown witnessed firsthand during her 20-year career leading healthcare initiatives, including Medicare Advantage plans. Amy has detailed her background and her “why” for improving the member experience in the Becker’s Payer Issues podcast and in Healthcare IT Today. Below is an audio interview of Amy Brown where she shared about her experience in the Medicare space.
How can Medicare plans strategize around millions of different voices? By identifying themes and disruptions in the member journey (at Authenticx, we call this the Eddy Effect), Medicare leaders can begin to create action plans around what their audience is directly telling them. Common pain points in the MA member experience include but are not limited to:
- Personalized care for members
- Member monitoring (ODAG/CDAG) and evaluations
- Measuring the effectiveness of agent training
- SDOH and access issues
- Plan oversight and audits
- Compliance verification and detection of fraud or misuse
- Member retention and satisfaction
Using AI to Improve Medicare Advantage Star Ratings
In a single, centralized hub, organizations can monitor crucial metrics that impact retention, growth, and core satisfaction components for Star Ratings. A highlighted use case from Authenticx describes a health maintenance organization (HMO) investigating the lack of opt-ins for its Medicare Advantage plan. By leveraging Authenticx’s proprietary Eddy Effect model, the HMO reduced member churn signals to 14% from 45% in four months and one of their MA plans saw an increase of opt-ins by 85%.
This strategy of using conversations helps improve the Medicare Advantage experience for members and operational teams, such as contact center agents, who often serve as the first (and only) face of the plan for members. As Medicare Advantage plans start getting insights from beneficiaries and members, they must keep in mind what is being communicated, where additional support is needed, if the feedback is a quality representation of their member population, and how they can better invest in personalization with intentionality. Approaching a new AEP season, prepare with the intention for 2025 and be ready to address Star Ratings with insights from member conversations.
For the most up-to-date changes and news about Medicare and Medicare Advantage, please visit the Centers for Medicare & Medicaid Services (CMS). For more information on Medicare, go to this resource. For more information on Medicare Advantage go to this resource.
Related Resources
- Checklist: 5 Ways AI Improves Medicare Advantage Star Ratings
- Using AI to Improve Star Ratings in 2024
- Customer Story Use Case: Preparing for Medicare Open Enrollment with Impactful Insights
- Using AI in Healthcare: Medicare and Medicaid Data
- Tips to Keep the Customer Journey Top of Mind During Medicare Open Enrollment
About Authenticx
Authenticx was founded to analyze and activate customer interaction data at scale. Why? We wanted to reveal transformational opportunities in healthcare. We are on a mission to help humans understand humans. With a combined 100+ years of leadership experience in pharma, payer, and healthcare organizations, we know first-hand the challenges and opportunities that our clients face because we’ve been in your shoes.
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