10/28/2025

Understanding the BPO Industry

What is BPO?

• Business Process Outsourcing
• Delegation of services to a 3rd party that supports global companies in Customer Service

Why Companies outsource?

1. Cost Efficiency

   • Reducing Labor, training, and operational expenses

2. Specialized Expertise

   • Accessing skilled professionals and advanced tools

3. Scalability and flexibility

   • Adapting quickly to changes and demand

4. Focus on core business

   • Freeing resources to prioritize growth

Call Center Business Types

• Voice: Phone Calls

• Non-Voice: Email, chat, back office

• Blended: Mix of both

  Inbound vs Outbound Customers call you You call customers (Support, Billing) (Outreach Campaign, Manual Callback)

Key Terminologies AHT - Average Handling Time CSAT - Customer Satisfaction FCR - First Call Resolution Adherence - Adherence to Schedules QA - Quality Assurance SL - Service Level

How Call Center Works Customers > Queue via Advocates

       Client
  BPO Executives

Support Operation Managers Team Leaders Advocates

Support Teams WFM - Workforce Management QA - Quality Assurance Training - Onboarding OPS - Manages day-to-day performance HR - Handles Employee relations, payroll, benefits IT - Support System Tools, headsets, network issues

Tools used in Call Centers ACD - Automatic Call Distributor IVR - Interactive Voice Response (Press 1 for ...) CTI - Computer Telephony Integration (Soft Phone) CRM - Customer Relationship Management (relationships and interactions) Knowledge Base - published collection of documentation; includes answers to frequently asked questions Call Recording and Quality Monitoring - allows companies to listen and to evaluate the recorded interaction and information sharing between its employees and customers

Compliance and Confidentiality

• Protect Customer Data
• Use only approved systems
• Follow security protocols

Member Service Advocate (MSA) Member Service Advocate assists with:

• Plan Enrollment Assistance
• Plan Coverage Explanation

Mandatory Actions

1. Greeting and Identification
2. Understanding the Issue
3. Willingness to help
4. Empathy and Assurance
5. Resolutions
6. FCR
7. Recap and Close

Other Call Actions

1. Monitoring Disclosure
2. Hold
3. Dead Air
4. Outbound Calls
5. Disconnected Calls
6. Contact Info Update
7. Potential CTM

Understanding the Issue

• "How may I help you?"
• "So you are calling to ?"

Willingness to help: "Let's take care of that right now" "I would be frustrated myself. I'm going to handle this for you" "Thank you for that information. Let me take care of this" "Absolutely, this is what I will do for you..." "I'm glad you called today. I know exactly what to do." "I understand, let me take care of this right now." "I know how you feel about that."

Restatement "Just to make sure I understand - you're saying that under your new prescription drug plan, you expected all your medications to be covered, but when you went to the pharmacy, at least one of them wasn't included, and you're unsure about why that is, is that right?"

"Yes, exactly. I don't know what's going on"

"Thanks for confirming. Let me take a closer look at your plan's formulary to see what might have changed and how we can help you find a covered alternative or next step."

Empathy - means recognizing the customer's feelings and showing that you genuinely care Assurance - is about giving the customer confidence that their issue will be handled properly. Using both together helps to build trust, calm frustration, and improve...

Resolution

1. Use internal tools first - Rely on resources like CSP, Job Aids, QRT, or TL before seeking external help.
2. Exhaust internal sources - Only turn to CDU, Resource Unit, etc., after internal options are fully used.
3. Think beyond the fix - Don't just resolve the issue- identify and address the root cause to prevent recurrence.
4. Escalate when needed - If root causes point to bigger issues, escalate appropriately.
5. Probe to empower - Ask questions to uncover gaps and educate the caller for lasting solutions.

FCR (First Call Resolution) "Is there anything else I can assist you with...?"

Recap and Close "Alright, Mr. Jackson, just to recap - today you called because your prescription for Lisinopril wasn't showing as covered at the pharmacy. I reviewed your plan details and confirmed that it is covered, but the issue was due to the pharmacy subiting it under the old plan. ID. We've updated your information in the system, and I've also contacted the phgarmacy to make sure they have the correct details moving forward.

Monitoring Disclosure (especially when contacting a pharmacy) "Hi Ms./Mr._________, I would just like to inform you that this call may be recorded for monitoring and training purposes."

No - Inbound Caller Yes - Third Party Joins the Call Yes - On speaker phone Yes - Language Line - Interpreter Calls Yes - All Outbound Calls

Placing Customer on Hold Reason > Permission > Expectation

Dead Air 60 seconds Make it a habit to make it 30 seconds

Outbound Greeting

• Be clear when stating your name and stating that you are calling on behalf of Cigna
• State the monitoring disclosure to ensure compliance
• Be straightforward in stating the name of the customer you are looking for. Reminder: After delivering the applicable Inbound and Outbound script, make sure that we follow

Branded Outbound Greeting "Hello, my name is (First name) and I am calling from Cigna. Before I continue, I want to let you know that because quality is important to us, this call may be monitored or recorded for quality and training purposes. May I speak with Mr./Mrs./Ms (customer's first and last name"

Branded Outbound Greeting "Hello my name is (First Name) and I am calling from Cigna. This message is for (Customer's First and Last).

Disconnected Calls In the event a call was disconnected prior to providing a resolution, you must:

1. Call the custome back imediately to finish the call and provide resolution to all their inquiries.
2. Document all information about the dropped call and the callback in the account notes section of the system.
3. If callback was unsuccessful, provide the customer's informaiton to a Mentor or Supervisore via mail.

Contact Information Update

• Be sure to remember to update the customer's phone # and ask for an alternate # as well.
• Update any P.O Box address to a physical address.
• Applicable to member and any authorized representatives. 1. POA (Power of Attorney) 2. Guardianship 3. Conservatorship 4. One-Time Verbal Consent during the call

Potential CTM Process

                     Frustrated Customer Hangs up
                                                |

MS0075_________________________| __________________________ |______________________________________ | | | Escalation Line Mentor/Supervisor Escalation by Mentor/Sup Via Email

CRITICAL REMINDERS

• Outbound calls cannot be used for enrollments - This is a CMS violation. If a customer wants to enroll, give them our customer service number and explain they must call us directly.
• Only refer customers to Medicare if instruccted by an internal resource - Other Medicare referrals are not allowed.
• Do not tell customer to contact Social Security directly; instead, guide them to their local office if needed.
• NEVER BLAME MEDICARE or imply we're waiting on CMS for actions like enrollment approval or payment updates.
• Avoid mentioning CMS as responsible for resolving customer issue during calls.

Path to Success Open - Open the call promptyl and dont forget to state name Listen and Acknowledge - Listen to the customer's request with your undividied attention Verificiation - Follow Standard PHI verification guidelines Probing Resolve Recap Close

Medicare Part D Plan

• Offers prescription drug coverage for Medicare Beneficiaries
• By private insurance companies who contact medicare
• Designed as cost sharing plan meaning the cost of the medications is split between the beneficiary, the prescription drug plan, manufacturers and medicare
• Beneficiaries who want to receive drug benefits must enroll with a prescription drug plans
• Types of Part D Plans:
  1. Stand Alone Drug Plans (PDP)
  2. medicare advantage + Prescription Drug Plans (MA-PD)
• PDP plans are purhcased by beneficiaries who have medicare A/B beneficiaries who enroll in a medicare advantage plan can chose a plan that offers prescription drug coverage included in the benefit package. NOTE: IF NO PART A/B PLAN, MEMBER CANNOT ENROLL TO PART D What are the different plan costs?

Premium (Amount): Amount paid for insurance coverage Deductible (dollar amount paid before insurance is applied): Pre-designated dollar amount of covered expenses that are paid by the insured individual, after which insurance coverage begins Copayment (Fixed): fixed amount paid by the patient at the time a medical service is rendered Coinsurance (%): A percentage of cost of an insured service

How PDP plans work:

• Medicare Part Dare divided into three coverage levels
• Each level has different cost sharing and drug spending req
• If the drug spending threshold is met, beneficiary moves to next level
• Plan year begins with deductible phase, beneficiaries move through three levels, each having spending limit
• Since beneficiaries are enrolled in a plan for a calendar year, all drug spending is tracked and resets on a yearly basis.
• Drug spending limits are adjusted annually based on Medicare's guidance

Drug spending out of pocket

• total amount of money spent on drugs regardless of the payer
• important to ensure beneficiaries are moving through three coverage levels automatically

Out of Pocket

• Total amount of money that the beneficiary pad on the drugs during the plan year
• beneficiary switches part D plans during a benefit year the amount will be carried over to new plan
• Includes payments made on behalf of a beneficiary by a friend, relative, most charities, and differente government assistance programs

What is NOT added to the Max Out of Pocket?

• Monthly Premium
• Drugs not covered by part D plan
• Drugs purchased outside the U.S.
• Drugs purchased at an out-of-network pharmacy
• Drugs not normally covered in a Part D plan
• Any payments made by the plan and payments made by:
  1. Group health plans
  2. Certain insurance plans and gov funded health programs such as TRICARE (Military), and the Veteran's Administration (Retirees)
  3. A third party with a legal obligation to pay for prescription costs (e.g. worker's comepnsation)

Three Coverage Levels of PDP plans? L1 - Deductible

• during this stage, if your plan has a deductible, you usually pay the full cost of your covered Part D prescription drugs up to the deductible amount/ If you're plan does nbot have a part D deductible amount, you enter the initial coverage stage and pay a copay or coinsurance

L2 - Initial Coverage

• During this stage the plan pays its share of the cost and you pay a copay or coinsurance for each covered part D prescription drug you fill uyntil your out-of-pocket drug costs reach $2,000 for the year. Once it is reached, you enter the Catastrophic Coverage Stage

L3 - Catastrophic Coverage

• In this stage you pay a $0 copay for each covered Part D prescription you fill.

What is a payment subsidy?

• A government incentive or assistance in the form of financial aid extended to an economic sector

What payment subsidies are available for benificiaries, with limited income and resources?

1. Medicaid
2. Extra Help - LIS (Low Income Subsidy)
3. SPAP/ADAP
4. Medicare Savings Program

Other Cost and Payment Terms

1. Deductibles
2. Prescription Drug Cost
3. Co-payments
4. Co-insurance

Who is responsible in paying the plan cost

• Benificiary/Member

  1. Direct Payment - monthly invoices are mailed out prior month and the customers pay directly with their preferred payment type and method
  2. SSA/RRB - SSA Deduction - authorized monthly premium automatically witheld for customer's SSA check, customer's need not to pay premium as the payments are deducted from their SSA/RRB accounts

• Subsidized Pay? ment - Government or Church Subsidy

  1. SPAP/ADAP - partial or full subsidy from state
  2. Burri - partial or full subsidy from diocese

'PWHO'

what is payment subsidy?

• a government incentive or assistance in the form of financial aid

What is the term corresponding to the source of plan PWHO

How can customer pay their plan premiums one time payment The total annual cost of the plan paid debit, credit - direct payment/ SSA/RRB ACH; checking or savings account

How can customer's pay their plan premium

• through website CIGNA.COM\MEDICARE
• automated system

Witholding - The corresponding part of the plan cost is automatically witheld from customer's SSA check/ RRB check - Subject to approval - Processing can take up to two months

Income Related Medicare Adjustment Amount (IRMAA)

What is IRMAA?

• The Income Related Medicare Adjustment Amount is an additional amount customers pay because of their annual income.
• paid directly to their Social Security not the plan

How do customer's pay IRMAA

• SSA notifies beneficiaries in november if they are assessed part d-IRMAA

Income related medicare adjustment amount

State Pharmaceutical Assistance Program

• State run and state funded programs that provide description drugs cost assistance along with plan premium assistance to low-income seniors and adults.
• Eligibility requirements, program standards, and benefits will vary between the states that do, and often change from year-to-year

Who qualifies for SPAP/ADAP

• each state has flexibility in determining their SPAP/ADAP eligibility requirements
• generally, residents may qualify for SPAP/ADAP based on their age, income level, or condition

How can a beneficiary submit an application

• Resident can apply directly with the state for SPAP/ADAP coverage
• Qualified SPAPs have the authority, under applicable state law, to request enrollment in a Medicare Part D, plan on behalf of the customers

if member does not want to pay that, it is expensive

: okay ma'am I understand options: extra help SPAP M3P Medicare Prescription payment plan Tier Reduction