Complaints — Make Sure They Are the Gift that Keeps on Giving

Have you ever received a gift you knew had value, but you just weren’t sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as the important pieces of information they are. Complaints are something we all wish would never be needed, but every health plan receives them. Our members have needs, and sometimes those needs don’t appear to our members to be met. In those instances, if we are lucky, the health plan receives the complaint. If we are not lucky, our members’ neighbors, acquaintances, doctors, or even worse — regulators and congressional representatives’ — receive the complaint.

Regan Pennypacker, Gorman Health Group’s (GHG’s) Senior Vice President of our Compliance Solutions Practice says it best, “Complaints, grievances, expressions of dissatisfaction — these are a part of life in the course of running any government program. The processes are in place to provide an avenue for your membership to speak openly about their dissatisfaction and provide you an opportunity to take that data, analyze for trends, and, if possible, make changes in an effort to improve quality.”

Here are four components for making the most of that opportunity:

1. Train staff to hear complaints. There is a delicate balance in Customer Service to identify complaints. Some Customer Service staff members are so focused on fixing the immediate issue, they don’t recognize the additional complaint concerns. An example of this is a member calling to change his or her primary care physician (PCP) because things are “not working out with this provider.” It is easy and beneficial to help the member change to a new PCP, but what is the underlying issue that needs to be explored? If the health plan doesn’t know what is going on, there is no way to resolve the matter for this caller or other members. Having staff trained to recognize when a complaint is presented is the first key step to successful complaint management.
2. Correct categorization of complaints. This is an often discussed topic as it is a high audit risk and a frequent audit finding. A complaint is identified, but what type of complaint is it? Customer Service is often the first to talk to members about their concerns.  Sometimes the call is an inquiry or an educational opportunity or a misunderstanding that can, with the right information, satisfy a member. Other times the call is regarding a complaint that is an appeal, grievance, coverage determination or organization determination, or a combination of several types of complaints. Ensuring knowledgeable staff and clear support tools are in place to correctly categorize those complaints allows members’ concerns to be heard and addressed and appropriate due process to occur. If a member calls to complain about wanting but not being able to get a specific medication, that will most likely fall under a coverage determination or appeal if it was previously denied by the plan. Obtaining all the details will allow for a thorough and correct determination. What if it is a provider who was not willing to discuss any other formulary options, even if the member explained the drug makes the member sick? Possibly there is a quality of care grievance that needs to be explored; carefully categorizing a complaint is the next critical step in processing complaints.
3. Empowered, knowledgeable staff who can thoroughly investigate the complaint. Regan summarized this well, “Skilled, knowledgeable, empowered grievance and appeal coordinators are key drivers in plan satisfaction. Yes, the complaints will still come in, but what are you doing about them? How are those addressing grievances empowered to turn that interaction into a positive customer experience?” Some of my greatest product loyalty has been developed when I called to complain about an issue, and the company representative listened, investigated, and resolved the issue. It wasn’t always resolved in the manner I wanted, but I knew I was heard and that what could be done was done.  People processing complaints have to understand the importance of a complaint reported to the plan and be empowered to manage that complaint in the highest customer-focused manner.
4. Tracking, trending, and root cause analysis. Often times there is a disconnect between all the information gained from complaints and ways to make that information useable to improve processes and quality. Most plans track their complaints and report them to the Quality Committee. Some plans analyze the information searching for trends that can be managed and processes that can be improved. They look at the root cause of the issue that caused the complaint to see what can be done differently going forward. They evaluate the data to see who else might be impacted and proactively work to remediate the situation. They truly see the value of the gift provided to them to improve their organization.

Complaints are like constructive criticism: hard to hear sometimes, but they can make a big difference going forward. Just as it takes a strong person to adapt to constructive criticism, it takes a change in culture to value complaints as an opportunity to change and improve. Finding the worth in your members’ complaints will make your plan a stronger, more customer-focused organization. Does your organization leverage the complaint gifts you receive and make them count? If not, you are losing a key opportunity on a gift you already have and just don’t know fully how to use.

At GHG, our consultants have worked in the weeds. We understand the processes and pain points health plan staff face on a daily basis. We are here to help you as you evaluate your program and adapt to an ever-changing environment. I would welcome the opportunity to talk to you about how we can assist your organization as you strive towards more compliant and efficient operations.

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