Communications between healthcare insurers (also referred to as healthcare payers or health plans) and their members and providers are among the most critical and consequential operational activities conducted. By thoughtfully managing member and provider communications, healthcare insurers can:

  • Improve Member & Provider Satisfaction
  • Reduce Member and Provider Service Calls & Inquiries Yielding Operational Savings
  • Positively Contribute to Industry Accreditations & Certifications 
  • Positively Impact Members’ Health
  • Positively Impact Total Cost of Care

A recent survey of 400 members of commercial and government-sponsored health plans by Pollfish found that members want to hear from their Health Plans more regularly.

"American consumers are hungry for information on how to improve their health, especially since they are carrying more of the direct burden as a result of the increase in high-deductible health plans in recent years. This desire creates an opportunity for health plans. They have a financial stake in improving member health, and have the resources to create and deliver these messages. The key is to bring information their members actually want, through the channel they want it delivered in, in a timely and personal manner. Fulfill those requirements and health plans can build a much stronger and less price-sensitive relationship with their members."

Dr. Howard DarvinChief Medical Officer, RxEOB

However, before healthcare insurers can begin to proactively look at opportunities to improve their communications, they must traverse an ever-growing gauntlet of challenges to meeting their basic correspondence requirements. Healthcare insurers have to navigate a unique set of external and internal dynamics to make their member and provider communications successful.


The healthcare and insurance industries face constant demands from regulatory bodies, changing market dynamics and, of course, their member and provider base. 

  • Constantly Evolving Regulatory Environment
    The Centers for Medicare and Medicaid Services (CMS) are continually issuing new frameworks and guidance with which health entities must comply. In addition, each state has its own unique laws and regulations that Healthcare Entities with which they must also comply. Many of the communications sent by health plans are either required communications or have specific requirements that they must meet (e.g., - privacy, content, timing, etc.). This is an additional consideration operational leaders must take into account during their communications planning.
  • Quality Scores May be Impacted by Member Experience
    Many health plans seek to be NCQA (National Committee for Quality Assurance) Accredited which has, as an example, member experience measures as part of the overall scoring. Failure to meet appropriate thresholds could negatively impact accreditation, and with customer communications being such a vital component of the member experience, it’s critical they are up to par.
  • Rapidly Changing Market Dynamics
    Health plans must adapt to continuously changing market dynamics by evolving their core and ancillary offerings as well as their capabilities. Organizations have to adapt to the rapid pace of change or risk being left behind. These changes to plans and offerings impact communications, which also must be adapted quickly.
  • Industry Consolidation
    Health plan competition is fierce and many plans are consolidating through mergers or acquisitions to better compete on breadth of offerings and to better manage administrative and operational costs. However, merging health plans can have a major impact on how they brand themselves and communicate with members and providers. A smooth transition and management of multiple brands and messages is vital to customer clarity and satisfaction.
  • Member Preferences and Expectations
    In an increasingly self-serve and on-demand society, members expect to receive information when they need it, in a way they can easily consume and understand, and via a channel of their choosing (e.g., postal mail, email, web portal, mobile app, etc.). An insurer’s ability to deliver on these preferences and expectations is directly linked to levels of customer satisfaction.

The internal pressures to reduce operating costs while improving operating efficiency all while maintaining a high level of member and provider satisfaction are additional stressors to health plan operators.

  • Multiple Data Sources
    Member and provider data at most health plans is managed across a series of different systems, databases, and vendors. Other critical information, such as plan and benefit data, is many times stored in different places. All this disparate information must be accurately synchronized in order to dynamically create and send accurate and comprehensible member and provider communications.
  • Multiple Service and Solution Vendors
    Many health plans leverage multiple software, service, and solution vendors to manage components of their operations. Plans need to tightly coordinate vendor activities to ensure expectations are communicated and delivered. Some vendors are not as skilled as others in managing the continuous, dynamic change that’s the hallmark of the healthcare insurance industry. This can be a dealbreaker for many, as most health plans need to be able to make changes to their communications up to the last minute.
  • IT (Information Technology) Applications and Systems Not Optimized for Dynamic Change
    The internal IT organizations at most health plans have to balance a very large amount of competing priorities. In order to ensure work is efficiently planned and delivered, they oftentimes institute controls related to how changes can be submitted and reviewed. This approach may be effective at an enterprise level, but can pose significant risk to implementing member and provider correspondence automation as design often needs to dynamically change right up until the next round of production.
  • Orchestrating Departments with Varying Priorities
    Sales, Marketing, Operations, Service, Compliance and IT teams often have varying views on what needs to comprise each unique piece of member and provider communication. Those, sometimes competing, demands need to be negotiated expeditiously to ensure communications can get out to members and providers on time.
  • Version Management
    Many member and provider communications vary by brand, market, and plan, resulting in many iterations and complexities while implementing, approving and delivering.  Having the right infrastructure to manage document versions is critical to ensuring accurate and timely communications.
  • Synchronizing Timing of Member Communications
    Oftentimes, members will be receiving critical information across multiple mailings. Members who receive these communications out of order will be confused and unhappy. In addition, this dynamic creates an increase in expense from additional member support requests that could have otherwise been avoided by accurate synchronization and timing of these mailings.

Every healthcare operations manager will tell you that the pressure to lower operating costs is constant and a daily struggle when trying to balance lower costs with providing a strong customer experience.

  • Complexity of United States Postal Services (USPS) Options
    Depending on size, health plans may be sending anywhere from thousands to millions of pieces of correspondence to their members and providers annually. The design and packaging of those pieces should be informed by USPS mail options (e.g., dimensions, weight, and postal class) along with their associated costs. Organizations can be significantly overpaying for postage if they don’t fully understand the options available.
  • Pre-Printing Versus Print On-Demand Because of advancements in on-demand printing and collation automation, organizations can now take advantage of mixing pre-printed items with dynamic, on-demand printed materials which can yield significant savings and eliminate obsolescence.

Industry Trends

The healthcare insurance industry is marked by perpetual change. Those organizations that can adapt and respond the quickest tend to be the most successful. Understanding and assimilating the latest and most vital industry trends can give a plan an immediate competitive advantage.

  • Personalization
    Members expect communications to be necessary and of value. In many cases this requires the information in the correspondence to be personalized to each individual member. Expectations and demands are particularly high during open enrollment, making the design and optimization of member welcome kits vital. Personalization needs can range from specific plan selections, programs they are enrolled in, or specific to their particular health needs (e.g., a reminder they are due for a colonoscopy or a mammogram).
  • Print to Digital
    Web and mobile technology has reached critical mass. 96% of Americans now own a mobile phone of some kind and over 80% of people own a smartphone (Pew Research Study). Members and providers are becoming more comfortable receiving health plan communications digitally with many preferring the speed and convenience of digital communications. Having a path for members and providers to receive their communications consistently across different delivery channels is critical.
  • Member Access to Data
    Health plan members want complete and transparent access to their data. Providing information via standard communications is a critical step to meeting those expectations. While upcoming regulatory changes, such as the CMS rules related to Interoperability & Patient Access, may not directly impact member communications, organizations should be looking at member data holistically when architecting solutions to such regulations.
  • Drive to Reduce Operational Costs
    Healthcare payers and TPAs have always been under pressure to reduce operational costs, however, with increasing transparency due to regulatory reporting and quality measures, there is even more pressure to rapidly identify and eliminate operational cost drivers. Member and provider communications can be a major contributor to operational costs, but also represent a major opportunity for cost reduction when managed well.

While the challenges to implementing and maintaining a successful and efficient member and provider communication plan are many, so are the opportunities to excel and deliver a world class customer experience. With the right vendor and technology solution, healthcare insurers should be able to successfully navigate the challenges and create a successful and lasting member and provider communication plan.