A CMS Compliance and Star Ratings Guide for Health Plan Call Centers
The 2025 CMS Call Center Monitoring Study is a cornerstone for both compliance and Star Ratings success in Medicare Advantage plans. This study encompasses two distinct evaluations: the Timeliness Study, which focuses on hold times and disconnect rates for compliance purposes, and the Accuracy & Accessibility Study, which directly impacts Star Ratings. With the study set to begin in February 2025, health plans must balance compliance mandates with quality improvement strategies to excel in both domains.
Recent lawsuits highlight the complexities and stakes of call center performance, underscoring the need for meticulous preparation and strong vendor partnerships. Low performance can lead to not only reduced Star Ratings but also disciplinary action from CMS, making this study a priority for every Medicare Advantage organization.
Understanding the CMS Call Center Monitoring Studies
The Timeliness Study
The Timeliness Study measures the performance of current enrollee and pharmacy technical help desk telephone lines. While these results do not influence Star Ratings, they are essential for compliance. The study evaluates:
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Average Hold Times:
Plans must maintain an average hold time of 2 minutes or less. -
Disconnect Rates:
Disconnect rates must remain below 5%.
Non-compliance with these metrics may trigger CMS scrutiny and require corrective actions to avoid further regulatory consequences.
The Accuracy & Accessibility Study
This component evaluates prospective enrollee call center lines and directly impacts Star Ratings. Key measures include:
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Interpreter Availability:
The ability to provide interpreter services for individuals in multiple languages. -
TTY Functionality:
Ensuring accessibility for hearing- or speech-impaired individuals. -
Information Accuracy:
Assessing the accuracy of plan details provided by customer service representatives (CSRs). While this is part of the Accuracy & Accessibility portion of the study, it does not contribute to Star Ratings calculations.
These measures are double weighted in Star Ratings calculations, reflecting their importance in overall plan performance.
Preparing for Compliance and Navigating Disputes
In addition to performance monitoring, plans must be prepared for potential disputes over call center results. Here’s what you need to know:
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Act Quickly on Results:
For the Call Center Monitoring Study, plans have the best chance of thorough review and correction if disputes are submitted within two weeks of the results being posted in HPMS. This initial window ensures timely attention to potential issues. However, plans can also submit disputes for Interpreter Availability and TTY Functionality results during the Stars Plan Preview window. CMS strongly encourages early submissions, prior to the preview period, to maximize the likelihood of resolution. -
Document All Calls to Provide Strong Dispute Evidence:
Successful disputes require clear documentation showing calls were incorrectly marked unsuccessful. Challenges to CMS methodology are not accepted. -
Be Proactive at Monitoring HPMS Postings:
Monitor HPMS postings closely, maintain detailed call logs, and partner with vendors who offer robust documentation tools to strengthen your dispute cases.
Building Success Strategies for Medicare Advantage Plans During CMS Monitoring
Use technology to elevate your performance. Take NexTalk and its Access Contact Center TTY technology. NexTalk allows your CSRs to take TTY calls directly on their desktop, without a 711 relay agent. This software reduces average hold times and disconnect rates, improves accuracy, and provides the data you need to dispute a call. They work exclusively in the accessibility space and have a patented TTY connection.
Integrating Vendor Support and Best Practices
Strong performance in the CMS Call Center Monitoring Study requires a seamless strategy blending internal operations and external vendor expertise. Here’s how health plans can prepare:
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Train CSRs with Purpose:
Equip your team to handle calls efficiently, responding accurately to CMS test calls while avoiding unnecessary member verification. Reinforce the importance of staying engaged during interpreter and TTY calls. -
Strengthen Technology and Systems:
Regularly test phone lines, IVR configurations, and TTY systems to ensure everything works seamlessly. Intuitive IVRs and clear routing reduce frustration and improve outcomes. -
Partner with Proven Vendors:
Work with vendors who provide detailed call logs, proactive system testing, and expert support. They should enhance compliance efforts while improving accessibility and accuracy metrics. -
Monitor and Adapt Continuously:
Use regular self-assessments to identify potential issues. Test phone lines from diverse locations, simulate member scenarios, and ensure all numbers in HPMS route properly. -
Emphasize Consistency Across Operations:
Ensure compliance with standard operating hours, maintain adequate staffing during peak times, and implement clear guidelines for handling TTY and interpreter calls.
Beyond Star Ratings: The Broader Impacts of Call Center Excellence
Strong call center performance enhances more than just Star Ratings. The CMS Call Center Monitoring Study overlaps heavily with the annual CAHPS survey, as customer service agents directly impact the Customer Service and Rating of the Health Plan measures. Exceptional call center experiences influence how members perceive their plan’s responsiveness, respectfulness, and ability to resolve issues. Benefits include:
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Actionable Insights:
Regular analysis of call trends helps identify and address the root causes of member dissatisfaction. -
Real-Time Member Feedback:
Implementing short post-call surveys or satisfaction polls gives immediate insight into member experiences and highlights areas for improvement. -
Service Recovery that Builds Trust:
Empowering CSRs with problem-solving tools can transform negative interactions into positive outcomes, strengthening member loyalty. -
Unified Commitment to Service:
Fostering an organization-wide dedication to customer service ensures consistency in all member interactions.
By aligning call center practices with CAHPS-specific language and priorities, plans can enhance both compliance and member satisfaction.
Conclusion
The 2025 CMS Call Center Monitoring Study is a pivotal opportunity for Medicare Advantage plans to demonstrate their commitment to compliance and member satisfaction. By integrating best practices and leveraging strong vendor partnerships, plans can excel in both the Timeliness and Accuracy & Accessibility studies. Success here not only safeguards Star Ratings but also reinforces regulatory compliance and enhances the member experience.
Are you ready to optimize your call center performance for 2025? Let’s work together to build a strategy that delivers results.
