OBJECTIVES: Customer service holds a pivotal role within a health insurance company, serving as the frontline interface between the insurer and its members. Being able to detect members who are having an exceptionally negative customer service experience is crucial to preventing issues from causing long-term dissatisfaction. Many of these identified cases involve complex medical issues where a prompt resolution provides a pathway to the care these members need.

METHODS: The Blue Cross and Blue Shield of Louisiana (BCBSLA) Customer Service department needed a way to prioritize and identify cases of greater urgency and severity, other than recognizing those with a high number of complaints. BCBSLA recognized members can have complex issues that remain unresolved and never express a “complaint” about it. These complex issues can grow over time and create more problems the longer they go unaddressed.

Implementing a ranking system enables BCBSLA to prioritize time-sensitive cases. The primary factor considered is a streak measure that takes the cumulative sum of all Customer Service interactions that have occurred within 15 days of an interaction. The count restarts if 15 days transpire without any contact to Customer Service. As a member’s streak increases in length, the complexity of their case tends to grow as well. Researchers also considered other metrics, such as the beginning to end duration of each streak and percent of complaints.

RESULTS: High streak scores are effective at detecting distressed callers and complex cases. Members with a streak make up about 15% of all members who contact Customer Service within a 15-day window.

CONCLUSIONS: This ranking system enables BCBSLA to identify and prioritize more urgent cases, leading to increased member satisfaction in which prompt resolution facilitates continued access to care.