If you are a hospital or a health insurance company (in the US) servicing Medicare and Medicaid patients then you know about CMS and CMS Auditors making mystery shopping calls. CMS.gov is the federal agency that covers the cost of elderly care via subsidies, grants and reimbursements.
To incentivize better public health and public service, CMS conducts an audit of all institutions that provide Medicare / Medicaid services. The audit covers all aspects of patient care, insurance claims, pre and post op explanations, customer services etc. CMS attributes a STAR rating to each entity on a scale of 5 stars with ½ star points, so a 4 STAR hospital is better than a 3.5 STAR one.
The value of an upgrade, even of ½ a STAR is in the millions for large hospitals or insurance companies. See the Cigna Group case to know the monetary impact (please cite them).
The audits are done using “mystery shopper” approach wherein a mystery shopper acts as a patient and goes through the motion like a normal patient would. They then provide the feedback to CMS.gov. The audits happen throughout the year but peaks between August and Jan, i.e. from before the enrollment season to just after it closes. For the rest of the year, the audits reduce to a trickle.
One of the parameters, with a 20 to 40% weightage in the audit, is customer service. The auditor calls into your contact center and interacts with the agent, like a normal patient would. They test everything from how long does it take for the agent to get on the line, whether an IVR was used to delay call connect with a live person, what languages are offered, whether the agent speaks fluently in the selected language, whether agent voice was clear and audible, the level of background noise, the explanation offered, and more.
To ensure that they remain “mystery shoppers”, the auditors do not use the same phone number they change their phone numbers after a few calls.
The Role of Contact Centers in CMS Ratings
As technology providers to hospitals and health insurers, our job is to be able to detect the call from a CMS auditor using AI if we need to, and inform your agent of the same, within 10 seconds. This would allow multiple things:
- If the call rings at a group of agents, then the best qualified agent can answer
- Knowing that a CMS call is in queue, agents can hang up the call they are active, to make themselves available to take this important call
- The floor around them can be quieter
- Supervisor or team lead can walk over to help
- The agent can follow the defined script to handle auditor calls
So, how can we go about this:
First we need to identity if the call is from an auditor
Since they keep changing their numbers, this requires a “living” database. And, since the calls we receive will be limited, it is important to build a community so we can “crowd source” this intelligence. That is exactly what we have done.
We screen calls at multiple hospitals and insurance companies and as each of them report having received a call from a CMS auditor, we add that to the living database and share that database amongst all our customers.
The cloud maintains a central database, collects this information from each customer’s node and resolves the merge conflict. Once it has a clean copy it pushes it down to each customer’s node, ensuring that eveyr customer has the latest “probable CMS auditor numbers”. This process is repeated every 5 minutes.
Then we need to alert the agent and supervisor
When the call is received from one of these “Auditor numbers”, our system swings into action. It receives the signal before the call is routed to the agent. At this time, it triggers multiple methods of notifications – it changes in-call display to “CMS auditor call”, it also triggers a MS Teams message that can be flashed to the entire group of agents and supervisor so everyone is aware, and lastly it can also light up a strobe light on the floor, so there is visual and audible alert, making sure no one misses the most important call of the day. All this is done within a few seconds of the call reaching the enterprise.
Take feedback and learn (repeat)
Each customer maintains their own internal control of dual-review (agent an supervisor listen to the recording) before reporting a number as CMS auditor’s. Once reported in their internal system, our system picks that up and updates the cloud.
Our system keeps a weighted score or probability of a number being used by a CMS auditor. Depending on number of people reporting this as CMS auditor or the recentness of it, the weightage is calculated. A number that is used and reported today has a much higher weightage than a number that was reported a month ago.
If an agent or supervisor reports a call as false CMS alert, that is taken into consideration too. Thus, the system learns from its mistakes and keeps itself up to date.
To Learn More about the CMS Auditor Call Detection Solution and how we can help you, fill the form below