Member services for a United States regional health plan

The client is a regional health plan in the south-eastern United States covering approximately 810,000 members across commercial, marketplace and Medicare Advantage lines. Member services handles benefit enquiries, claims status, provider network questions and prior authorisation status. Roughly 22% of membership is Spanish-speaking.

Member services performance had degraded to a level attracting regulatory attention. Average speed of answer stood at 408 seconds, well beyond contractual and regulatory expectations. Annual enrolment abandonment exceeded 30%. The plan had received complaints escalated through state channels, and its Medicare Advantage star ratings exposure on member-experience measures had become a board-level concern with direct revenue consequences. Repeat contacts consumed a large share of capacity. Roughly 37% of claims-status enquiries were repeats from members who had received an incomplete answer, each consuming capacity that would otherwise have reduced the queue. The compliance dimension constrained options. Member services handles protected health information, and the plan's prior offshore experience had produced an internal audit finding on access controls that made its compliance function resistant to any offshore proposal, with two board members preferring onshore-only despite the cost. Onshore expansion was not affordable at the required scale without breaching the plan's administrative expense ratio.

Corpshore Colombia was selected after a compliance-led evaluation in which the plan's privacy officer participated from the first meeting. The material factors were the documented HIPAA-aligned control environment, the Toronto parent governance providing a North American contracting counterparty, and Corpshore's acceptance of a right-to-audit clause with on-site inspection in Bogotá.

Nearshore geography carried independent weight. A flight of roughly four hours from the south-eastern United States made physical audit practical in a way the plan's prior offshore arrangement had not, and the privacy officer has since conducted two onsite reviews.

Eighty-six agents in Bogotá: 66 English-primary and 20 Spanish-bilingual, with seven team leaders, three QA analysts and a dedicated compliance lead reporting functionally to the plan's privacy officer. Coverage runs 08:00 to 20:00 US Eastern Monday to Friday with extended weekend hours during annual enrolment, scaling to 120 agents for enrolment. Work is performed in a physically segregated area with clean-desk enforcement, no personal devices and session-level access logging.

Attack repeat contacts, not queue time. Average speed of answer was the symptom; repeat contacts were a substantial part of the cause. The first intervention targeted resolution completeness on claims status, removing demand from the queue rather than adding supply. Complete-answer protocol. Agents were trained and measured on providing a complete disposition, what the status is, why, what happens next and by when, rather than reading a code. Quality scoring was rebuilt around completeness. Compliance as an operating discipline. The dedicated compliance lead runs monthly control review, quarterly access recertification and a documented incident protocol, producing the same reporting the plan's internal functions produce.

Enrolment surge as a planned event. Annual enrolment capacity is planned from July, trained by September and live in October, drawn from a returning pool where possible.

Member services average speed of answer

Average speed of answer fell from 408 seconds to 60 seconds by month 12. Annual enrolment abandonment fell from over 30% to 6.2% in the first enrolment period under the engagement. Repeat contact rate on claims status fell from 37% to 12%, which the plan identifies as the primary driver of the queue improvement. The plan recorded no HIPAA-related audit findings against the Corpshore operation across two review cycles, and its privacy officer completed two on-site reviews.

The complete-answer protocol and rebuilt quality rubric have been adopted by the plan's remaining in-house service functions. The compliance operating model has become the plan's standard for all outsourced functions. Corpshore Colombia has since been engaged for the plan's provider services line.