Achieving 4-Star CMS Ratings for Leading Health Insurance Providers
Solix Case Study
Situation
A high CMS Star Rating isn’t just a badge of honor—it’s a strategic asset that drives financial performance, growth, compliance, and member satisfaction. Recognizing that internal teams were not always positioned to achieve a high star rating, providers turned to their long-time, trusted partner, Solix, to fill the gap and deliver high-quality contact center support.
Objectives
- Provide expert-level support for CMS test call scenarios across all required hours of operation.
- Proactively support clients’ efforts to earn and maintain a 4-star CMS rating.
- Integrate seamlessly with internal workflows to ensure an exceptional and reliable member experience.
Challenges
- Ensuring total coverage of CMS test calls, during the testing window annually between February and June.
- Maintaining agent readiness and alignment with evolving CMS evaluation criteria.
- Supporting client performance metrics without burdening internal resources.
Solution
Solix implemented a comprehensive support strategy tailored to the unique needs of large health insurance organizations. The approach included:
- Full CMS Test Call Coverage: Solix provided seamless after-hours and overflow call handling to ensure CMS calls were answered promptly.
- Supplemental Agent Training: Agents received targeted training focused specifically on CMS test call scenarios and best practices for attaining top scores.
- Strategic Scheduling: Solix adjusted staffing schedules based on its industry knowledge of when CMS was most likely to place test calls.
- System Integration: Solix agents were fully embedded into client systems and workflows, ensuring a smooth, brand-aligned experience—indistinguishable from in-house support.
Results
- Annually Achieved 4-Star CMS Ratings: Solix helped its clients consistently meet 4-star scoring criteria.
- Well-Prepared Agents: Trained agents delivered high-scoring responses, improving CMS test call performance.
- Optimized Schedules: Strategic schedule adjustments aligned agent availability with high-probability CMS call windows.
- Ongoing Operational Value: Solix reduced internal strain and maintained high standards without disrupting client operations.