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Call Center Optimization Has Major Impacts on 2023 Star Ratings

In 2020, when CMS shifted the star rating system from being heavily weighted on clinical care and health outcomes to one that was weighted toward the patient experience, plans started paying more attention to their member touchpoints. Historically, the patient experience was thought to be a direct correlation to the provider relationship. Focusing on the term “patient” did not always correlate to the “member” experience and the touchpoints a health plan could manage - or should manage - through monitoring and continuous improvement plans. The 2023 star rating changes demonstrate the clear expectation that the health plan focus on member experience. CMS’s changes to the cut points and weights continue to put the member first and focus on the member experience.


What does it actually mean when CMS has made changes to the “cut point”? Simply that the low-end outliers are being removed. The measure weight of the patient experience/complaints and access measures were increased from a weight of 2 to a weight of 4, meaning the impact of CAHPS survey results and CMS Call Center monitoring are now doubled. For some organizations, as a result of these changes it will prove harder to hit 5-star performance in these measures, and any misses will have more impact on the overall score.


The Call Center monitoring, as an example, is not an opinion survey; it is a direct and measurable outcome of administrative compliance.


How confident are you in your ability to prevent and detect non-compliance? How confident are you in your ability to pivot and correct non-compliance within a timeframe that produces meaningful results?


The common failures that we see within organizations are:

  • A lack of active monitoring in place to create needed visibility;

  • A lack of change management or ability to deploy active mitigation strategies; and

  • A lack of oversight – or independent oversight – of delegated vendors that manage prospective member call centers, member call centers, pharmacy technical help desks and grievance & appeals.

The Accuracy & Accessibility Study is conducted on prospective beneficiary call centers (based on the phone number the plan has listed in HPMS). This study is being conducted from February – June 2023 and there are steps you can employ NOW that can help performance this year. To test preparedness to meet these metrics with high marks, ask whether the following best practices are in place:

  1. Refresher training has been provided to all your Member Call Center staff on answering TTY calls and practice calls have been performed.

  2. The Call Center staff has job aids on how to work TTY software and use TTY lingo, such as using “GA” for Go Ahead and “SK” for Stop Keying

  3. Staff has been trained on the questions from CMS and has job aids with the correct answers for every PBP offered

  4. Staff has been trained on the Tips for Success/Best Practices based on the annual CMS HPMS notice and your prior year results

  5. Staff has been trained on how to identify a potential monitoring call and flag or categorize a call as a CMS monitoring call (“Are you the right person to answer questions about…?”)

  6. Staff scripts or processes in place do not require having a caller’s name, date of birth or any other identifying information before answering general plan information

If all of the tactical elements are covered, ask if there are measures in place to detect any non-compliance. Are you seeing TTY calls coming in? Are you ensuring those calls are automatically being reviewed for accuracy, completion, and timeliness? Are you seeing your staff connecting with your interpreter service? Are you ensuring those calls are automatically being reviewed for accuracy, completion, and timeliness?


The CMS Call Center Monitoring spans a period of four months and you can monitor and make changes while you are in the CMS monitoring timeframe. If you need help with testing, preparedness, or monitoring, contact us for help.

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