Fulfillment

The act of engaging our customers with Healthjoy products and services is called Fulfillment. Think of fulfillment as anything the Concierge team does to advocate for the customers' needs. 

There are 3 stages to Fulfillment:

This course will walk you through each step of the Fulfillment process. 

Stage 1: Intaking Fulfillment

Stage 1: Fulfillment Intake

Stage 1

Intaking- Completed by the front line HCCs taking calls and chats from customers. Stage 1 HCCs are responsible for

  • Actively listen to the customers expressed needs/concerns
  • Assessing the customer's account (insurance plan, HJ plan, health profile) 
  • Considering the customer's concern & account analysis before determining the best course of action to have those needs addressed and resolved. 
  • Submitting a request (ticket) identifying the customer's issue and what needs to be done, to the Fulfillment team for completion

 In this stage, it is important that all front line employees be an expert at Healthjoy's products and services along with a critical expertise in knowing and understanding insurance and people. ‚Äč

Stage 1: Needs Assessment: Fact Finding

There are 3 key competencies that a Stage 1 HCC must possess in order to act in the best interest of the customer and show the most value in the magic of Healthjoy. 

As HCCs, our role is to fact find to the root of the customer's needs through a series of clarifying questions and statements. This requires HCCs to have a working knowledge of Healthjoy's products/services, insurance expertise and the art of understanding people. 

Below are questions and statements that Stage 1 HCCs should be asking, in addition to analyzing a customer's account, to get to the root of a customer's need. 

  1. Understanding the Customer

    • Do you currently have insurance?

    • Is there a specific concern that you'd like to address with the doctor?

    • Are you taking any medications?

    • How often do you visit your doctor? 

    • Are you seeing any specialists?

    • Do you have a medical condition that you're needing treatment for? (diabetes, high blood pressure, COPD)

  2. Insurance Expertise

    • Are you aware of the free preventive services included with your major medical plan?

    • Have you already chosen a physician to manage your healthcare needs?

    • What services are looking to make sure you have coverage for?

    • Are you aware of the differences between dental insurance and dental discount plans?

    • Do you know how much your medications will cost you under your current insurance plan?

    • Are you aware of the penalties for not having insurance coverage?

    • It looks like you may be Medicaid eligible. Have you already applied?

  3. Understanding the Product/Services

    • We have Board Certified Physicians on staff that can treat that for you over the phone
    • What dental services were you looking to have performed?
    • If you send us a copy of your bill, we can review it and determine if any errors have occurred
    • We will follow up with the billing dept of that hospital to see if we can negotiate the cost of that bill
    • We can designate that PCP, with your carrier for you
    • Even without insurance, we can locate a low cost physician who bills according to your income. 

Example:

  • If a customer is calling for assistance with locating a provider, HCCs should be using fact finding questions to determine what their need is and assess how we can assist in the interim and on a continued basis. Is there any particular issue that you'd like to address with the doctor? 
  • If a customer is looking to cancel their service, HCCs should use fact finding questions to get to the root of their needs and assess how we can assist from there. Why are you looking to cancel today?
  • If the customer is on the line and you pick up on a possible need that the customer may not have mentioned, we should address their immediate questions first, then add value by addressing the needs that weren't stated.I heard you coughing. Although I know that wasn't the reason for your call, keep in mind that we have Board Certified doctors on staff that can treat cold and flu symptoms over the phone and prescribe you medication, if needed, right over the phone. 

 

Fact Finding Result: We add value to the Concierge service that Healthjoy offers while advocating for the best interest of the customer. 

Applying Your Knowledge: Scenario 1

Value in Fact Finding

 

  • On a short term plan, if a customer is seen for anything other than a new injury or illness, the intended visit will not be covered.
  • The customer may have some minor concerns that can be treated using Healthjoy's Telemed/Health Chat service, instead of paying for a visit.   

Had no additional fact finding been done and we sent the customer to an in-network physician, there is a possibility the customer may have initially been happy with the service, until they later received a bill for a visit they thought was covered. 

It's best to eliminate any potential for unexpected costs, wherever possible. This can only be done through an assessment of the customer's needs. 

Stage 2: Completing Fulfillment

Stage 2: Completing Fulfillment

Stage 2

Completion- Completed by the Fulfillment team of HCCs. The fulfillment team reviews the request submitted by the Stage 1 HCCs, and completes whatever request is listed in the ticket (i.e. Confirm cost of procedures, locate a physician, Telemed, etc). 

Example: Stage 1 HCC submits a ticket to find a Primary Care doctor. 

The Stage 2 HCC would be responsible for finding that doctor and honoring any preferences listed in the ticket (i.e. female doctors only)

Stage 2: The Process-Medical

Medical Fulfillment

Insured Customers

1. Go to customer's Houston profile page.

2. Click on HJ Search.

3. Customer's plan info will be pre-populated.

4. Select Is PCP check box or Specialty Group to search for nearest providers (Coordinate search is based on customer's home coordinates, not just zip code). Note: Zip code is just another term for a postal code. 

5. Select Doctors or Facilities to specify search.

6. Contact Providers until you locate 3 viable options

 

 

 

 

 

 

 

7. Once provider is confirmed, look for answer templates. Modify and confirm text template as needed.

8. Chat info to customer

Uninsured Customers

1. Use the resources available to local clinics/ Dr. offices

2. Contact providers until you find a viable option

Key Things to Keep In Mind:

If the provider's office forces you to give more details about who you are, inform them that:

  • You are an authorized representative for the patient
  • GoHealth Access is the customer's health care advocate

Key Things To Look Out For:

  • Always be sure to notate the name of office personnel you spoke with to confirm network status
  • If the customer had an urgent need, HCC should be chatting as well as calling the customer, to ensure info has been received (at least two attempts should be made)
  • If an appointment was scheduled, then appointment needs to be created in Houston, prior to contacting the customer.

Stage 2: The Process-Dental

Dentemax

Call the provider's office to verify plan participation

Verbatim: "I am calling to verify that your office is in-network with the Dentemax Discount program."

        If office accepts plan:  "Do you have the 2016 Dentemax fee schedule?" 

        If not, office can contact Dentemax directly at 800-752-1547 Opt. 2, Opt. 2.

              If office says they accept Dentemax PPO only, or if they do not accept discount plan:

"I see that you are listed as a contracted provider for the Dentemax discount plan. We're calling to verify you have the updated fee schedule before we refer a member over there."

 

Keep In Mind:

  • The Dentemax discount plan is a standalone plan. The member is responsible for up to the amount that is listed on the fee schedule. There are no claims to process.
  • Ask for name of the person you are speaking with and notate in the ticket (Contact: Ashley). 

Careington

Call the provider's office to verify plan participation

Verbatim: "I am calling to verify that your office is in-network with the Careington POS discount plan."

       If office accepts plan:  "Do you have the 2016 Fee Schedule for Careington POS discount plan?"

                 If not: HCCs can fax the fee schedule to the provider. See Knowledge Base for details on sending.

        If office says they do not accept Careington POS discount plan:

"I see that you are listed as a contracted provider for the Careington POS discount plan. We're calling to verify you have the updated fee schedule before we refer a member over there."

 

Keep In Mind:

  • The Careington POS plan is a standalone discount plan. The member is responsible for the amount that is listed on the fee schedule. There are no claims to process.
  • Ask for name of the person you are speaking with and notate in the ticket (Contact: Ashley). 

Stage 2: The Process-Vision

Outlook Vision

Call the provider's office to verify plan participation

Verbatim: "I am calling to verify that your office accepts the Outlook Vision Services Discount plan."

         If office accepts plan: "Are you able to verify what the discounts are?"

                 If not: Refer to Outlook Vision website for discounts.

        If the office says they do not accept the discount plan:

"I see that you are listed as a contracted provider. We are calling to verify you accept the plan before we refer a member over there."

 

Keep In Mind:

  • Ask for name of the person you are speaking with and notate in the ticket (Contact: Ashley). 
  • If customer has already had services but did not receive discount, Healthcare Concierge should refer customer to Outlook Vision directly so that they can reimburse customer for discount amount.

Eyemed Vision

Call the provider's office to verify plan participation

Verbatim: "I am calling to verify that your office accepts the Eyemed Vision Discount plan."

         If office accepts plan: "Do you have the fee schedule?"

              If not: "I'll go ahead and fax the fee schedule to your office, Can you provide me with your fax                                  number?"

        If the office says they do not accept the discount plan:

"I see that you are listed as a contracted provider. We are calling to verify you accept the plan before we refer a member over there."

 

Keep In Mind:

  • Ask for name of the person you are speaking with and notate in the ticket (Contact: Ashley). 
  • EyeMed has its own vision insurance program in certain states. If provider is trying to look up benefits by Member ID, explain to provider how to verify using group number and not member ID. 
  • Provider should be able to verify benefits by looking up Group Number and the name of the discount program is Careington International (can also use Careington POS)

Stage 3: Communicating Fulfillment

Stage 3: Communicating Fulfillment

Communicating fulfillment is quite simply the process of relaying the information found, to the customer. 

This is typically done via chat, but can also be achieved through a phone call or email, upon a customer's request.