From a cancer patient: “I had to change insurance in the middle of my eight-month treatment plan. Now I’m waiting to see if my oncologist and current chemotherapy drugs are covered. If they aren’t, I don’t know what I’m going to do. The approval and appeal process are overwhelming.”
From an OB-GYN: “I had a first-time mom due on January 3. She begged me to induce before the end of the year because she’d already hit her insurance deductible. Waiting to deliver until the new year meant paying thousands more in out-of-pocket costs. It’s a real challenge balancing patient care with insurance limitations.”
From a retiree: “In September, the cost of my prescriptions went way up. Turns out, I’ve hit something called the ‘donut hole’ for Medicare. Now I’m shopping around to find which pharmacy offers each drug at the lowest price and enrolling in discount programs to help. I’m not sure how long it will be until Part D kicks back in. Is it always this complicated?”
From a physical therapy practice: “One insurance company is rejecting our payment submission codes. We’ve been trying to resolve the issue for months. We finally had to give up because it was taking too much time. Now we have to tell those patients that we no longer accept their insurance and they have a large balance due.”
These are real stories. Millions just like them plague the health payor industry. This overly complex, highly regulated $1.6 trillion business impacts us all—from patients to workplaces, healthcare systems to individual providers.
Everyone needs healthcare at some point.
Health insurance plays a vital role in helping patients access the care they need. By focusing on healthcare payors as an integral part of the patient experience (PX), companies can improve lives.
The best way to do that?
- Make it easy.
- Make it personal.
- Make it caring.
The High Price of a Poor Health Insurance Experience
The goal of insurers and affiliated payment companies is keeping people healthy. Yet the complexity of the system often undermines this goal, impacting both business and member well-being.
In the 2023 U.S. Consumer Study by Qualtrics, health insurers ranked 16 out of 20 industries—just ahead of federal agencies, airlines, and car rentals. These rankings reflect important concerns:
Patients
- 58% of insured adults reported issues with their health insurance in the past year, including denied claims, provider network problems, and pre-authorization hurdles.
- 36% of insured adults struggle to understand what their insurance covers the same KFF study found.
- 4 in 10 insured adults delayed or skipped care due to cost in the last year, cutting across all income levels.
Providers
Who Pays?
Healthcare payors negotiate rates for healthcare services, pay provider claims, and collect payments from members. Payors include private health plan providers like UnitedHealth Group, Elevance Health, and Humana, as well as public plans including Medicare and Medicaid. In some instances, providers also function as payors. This applies to the Department of Veterans Affairs or healthcare systems offering their own medical plans.]
- 80% of doctors say insurance policies impact their ability to provide care.
- Physicians and staff spend 14 hours per week on prior authorizations.
- 56% of nurses report reduced job satisfaction due to administrative tasks.
- 50% of hospitals report more than $100 million in unpaid claims older than six months.
Insurance payment issues affect everyone across the entire U.S. healthcare system. But in every challenge lies an opportunity. Many insurers are stepping up to make major improvements to the customer experience. By focusing on what they can control, they are making meaningful strides to improve outcomes—because, ultimately, lives depend on it.
Getting Started with the Healthcare Experience Index
Understanding how to improve begins with knowing what needs work. The Qualtrics Healthcare Experience Index defines the benchmarks that drive a high-quality customer experience: success, effort, emotion, and trust.
- Success – Was the person or entity able to accomplish its goal?
- Effort – How easy or difficult was it for them to accomplish their goal(s)?
- Emotion – How did the effort make them feel?
- Trust – How confident did they feel in the organization’s ability to meet their goal?
According to the Qualtrics XM Institute, the health insurance industry scores lowest on effort and emotion. Consumers report increased difficulty in working with insurers and navigating complex processes to receive care. The study also shows that payors struggle forging an emotional connection and displaying empathy for their customers.
Assessing the four drivers against every touchpoint along the customer journey can help health insurers spot core issues impacting the patient and provider experience. By identifying the largest gaps between customer perceptions of what should happen and what actually occurred, payors can pinpoint specific opportunities for improvement.
Every Member’s Experience Matters
Walker’s in-house healthcare experts collaborate with insurance providers and payors to transform the member experience amid today’s complex industry challenges. Leveraging the Healthcare Experience Index, we assess performance across the four key drivers and implement strategies for continuous improvement. Ready to elevate your member experience? Partner with Walker—a Qualtrics leader in turning healthcare insights into action.
Strategies for Healthcare Payors to Improve the Customer Experience
Despite an industry riddled with red tape, scissors are everywhere. While the process may be slow and rigorous, even small changes can add up to big advancements. The reward is worth the work: better health outcomes, better business results, and a better experience for everyone.
Evaluate Existing Efforts
Launch the improvement process by assessing current performance. The Qualtrics XM Institute’s Customer Experience Competency and Maturity Assessment evaluates a healthcare payor across six competencies to identify program strengths and weaknesses.
By identifying the current maturity level, teams get a better gauge of where to begin the work and invest their time. The process includes identifying what customer data and insights already exist to create a progress road map.
Develop a Customer Journey Map
Journey mapping is the process of forming a visual representation of a customer’s interactions with an organization. The process helps teams understand the steps customers take when they interact with a business.
Having an in-depth understanding of the customer journey can help health insurers act on customer pain points and replicate what already works well. The process assists teams with grasping what a customer must go through (effort) to achieve their goals (success) and how those touchpoints make them feel (emotion).
Payor Improvements in Action: Geisinger Health
How can an insurer lower healthcare costs by nearly 8% while improving patient care?
Pennsylvania’s Geisinger Health System did just that by partnering with its affiliated health plan to launch ProvenHealth Navigator®. This innovative program focuses on care coordination, preventative care, and chronic disease management. Geisinger Health Plan members receive personalized care management from dedicated teams of nurses and pharmacists, who leverage predictive modeling to identify high-risk patients needing early intervention.
By using clinical and claims data, the initiative created community-based resources to promote healthy behaviors, prevent disease, and educate patients on prescriptions. As a result, the program not only reduced costly hospitalizations but also improved access to primary care and resolved more medical issues before they escalated. Over 7.5 years, this collaboration significantly enhanced patient outcomes while achieving a nearly 8% reduction in healthcare costs—proof that proactive, coordinated care benefits both patients and payors alike.]
Create a journey map for each type of customer. Depending on the role of the payor, this might include patients, hospital systems, employers, pharmaceutical companies, brokers, and government entities. Each goal also needs a journey map, which may be submitting a claim, conducting a prior authorization, or locating a provider.
Assess each touchpoint along the journey using four main categories:
- Customer behavior – What is the customer trying to do?
- Customer attitudes – What is a customer feeling?
- The “on-stage” experience – What is the customer directly interacting with?
- The “off-stage” experience – What needs to be in place that might be missing?
Establish a Listening Architecture
Developing a deep understanding of customer needs requires a Voice of the Customer (VoC) program to determine what stakeholders are saying. VoC captures customer needs, expectations, and understandings. The process uses customer preferences, problems, and complaints as insights to make improvements that impact the customer experience and business outcomes.
Start by assessing the current listening architecture to determine what channels capture VoC. This might be CAPHS surveys, recorded customer service calls, or employee feedback forms. Examine what people or entities are saying and extract actionable insights.
Next, identify the blind spots where customers are talking, but you are not listening. Excluding or limiting channels decreases the depth and accuracy of customer insights. Develop a systematic method for collecting feedback, including unstructured data, across these channels.
Do the Research
What are customers saying? How is the business performing? What are competitors doing?
Ask the right questions to drive research that explains current performance. Examine existing data and identify what is missing to understand what improvements customers want or need. Conducting in-depth research helps payors identify the largest pain points and prioritize their efforts to make the biggest gains.
Customer research from the Qualtrics XM Institute reports that health insurers tend to perform worst in customer service, claims management, and coverage confirmations. These are great places to start working on the customer experience.
Emphasize Empathy
Developing empathy in healthcare is much easier when somebody is more than a number or condition on a computer screen. Looking into worried eyes, exchanging a compassionate smile, or holding a tender hand transforms someone from patient to person.
Unfortunately, health payors lack access to these one-on-one relationships that develop emotional connections. A lack of empathy leads to a limited understanding of the customer. People want to feel cared for inside and outside of their doctor’s office. Insurance providers and their affiliates can develop empathy using four key strategies.
Personalization
Figuring out who your customers are, and their individual needs, drives every touchpoint along the experience journey. Develop personas that capture the needs, goals, behaviors, and motivations of each customer group. Give each persona a face and a name.
“You are an 18-year-old that just graduated and broke your leg. You just got your first health insurance bill. Now what?”
“You are a 59-year-old smoker in rural Ohio. Your doctor wants an MRI to check for lung cancer. What’s next?”
“A pharmacist needs to fill a prescription for a waiting patient that requires a prior authorization. What’s does he do?”
Each type of customer has vastly different demands of the insurer. Payors then can use the details to develop more personalized processes and products that better meet customer needs.
Frontline Listening
Perhaps no one understands the customer experience better than frontline staff. Customer service representatives interact daily with members and see firsthand the challenges they face. Their day-to-day work is full of valuable insights on pain points, frustrations, and potential improvements.
Frontline staff are particularly effective in revealing denied claim patterns, highlighting where patients struggle with pre-authorization, and sharing real stories of how payment delays affect care. Payors who actively seek feedback from these professionals gain a clearer, more human perspective on the healthcare journey. Incorporating their input into decision-making leads to practical solutions that reduce administrative burdens, improve patient outcomes, and foster greater trust.
Equity and Inclusion
Every customer is different, which makes developing a consistent, high-quality experience challenging. Think about the 89-year-old grandmother who only speaks Vietnamese. The one-week-old baby in the NICU and his parents. The family in rural New Mexico living more than two hours away from any specialized medical care.
Key is knowing what issues beyond the control of the payor exist, and factoring those into the experience. Consider variables like: language, education and reading levels, socioeconomic status, racial and ethnic diversity, type of care needed, and access to support systems. Address the impact of demographic, psychographic, and other considerations along the customer journey.
Appreciating and accounting for people’s differences and unique qualities goes a long way in forging a better relationship.
Storytelling
Research out of Stanford University found that people remember stories 22 times more than facts alone. Create empathy for patients and providers by telling their story. Share their individual journeys. Include actual customer quotes about their experience. Appeal to as many senses as possible by using call soundbites, showing member pictures, and discussing the emotions that capture the customer persona.
Storytelling makes customers relatable and helps form strong connections. A well-crafted story is a powerful persuasion tool. Presenting data in a way that speaks to an audience’s emotions, values, and experiences helps influence decision-making and increases buy-in. Stories motivate healthcare payor teams to build a better experience.
Create the Culture
No amount of effort can improve the customer experience in healthcare without an organizational culture to support the demanding work. You must have buy-in from internal stakeholders who care about customers and want to make a positive impact in the insurance industry. Start by generating executive support. Leverage research findings and listening architecture data to establish an urgency for change. An endorsement from senior leadership must include resources and a financial investment for improvements.
Further develop a customer-centric culture by:
- Outlining specific goals and creating data dashboards that emphasize progress over perfection.
- Celebrating small victories and the people making a difference.
- Creating ample opportunities for training and development around meeting customer needs.
- Empowering team members to make decisions that benefit members.
- Consistently seeking internal feedback and showing employees that their input creates action.
Consider a customer-centric culture as the ultimate predictor of success. Emphasizing and supporting the right internal behaviors generates the right external outcomes.
Rethinking the Healthcare Payor Relationship
Accessing healthcare insurance does not need to prompt fear, frustration, and confusion. Instead, it can spark trust, reliability, and a sense of true care. By systemically enhancing the experience provided to members, health insurers can seize a unique opportunity to stand out and distinguish themselves in the market.
Investing in a better experience—for customers and employees—simply requires starting small, thinking big, and taking the first step toward continuous improvement. In fact, putting yourself in the shoes of the customer is the most powerful motivator for positive change.