De-Escalation
The name of the technique that allows an angry customer to feel heard.
What is venting?
HIPAA stands for
Health Insurance Portability and Accountability Act
Definition of Fraud:
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or to defraud any health care benefit program or to obtain any of the money of property owned by, or under the custody control of, any health care benefit program.
The definition of small talk
Polite conversation about unimportant or uncontroversial matters, especially as engaged in on social occasions.
Clark Resources Core Values
•Responsibly provide a great member experience
•Empathize with the needs of each member
•Support the client’s mission
•Passionately take the extra step to assist members
•Encourage our colleagues to be the best
•Care for both our internal and external customers
•Thankfully accept our careers & the opportunity to make a difference in the lives of others
When dealing with an angry caller, it is best to avoid the following actions.
What are:
Hanging up on a member
Becoming verbally abusive
Placing the member on hold.
Summary of the HIPAA Law:
To establish basic privacy and security protection of health information.
To guarantee individuals the right to access their health information and learn how it is used and disclosed
To simplify payment for health care.
Definition of Waste:
•Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Acceptable Small Talk (list 3)
Weather Music
Pets Movies
Sports
Food
The Six Basic Needs of Customers
•Friendliness •Understanding and empathy
•Fairness •Control
•Options and alternatives •Information
True or False:
The process of de-escalating calls will help both customers and employees to have a positive experience.
True
PHI stands for:
Protected Health Information
Definition of Abuse:
•Abuse Payment for items or services when there is no legal entitlement to that payment
Unacceptable Small Talk
Politics
Religion
Personal Finances
Gossip
Offensive Jokes
Key Customer Service Skills
Patience
Attentiveness
Clear Communication Skills
Product Knowledge
Name this technique:
It allows you to put yourself in the customer's place and understand what they are feeling.
Empathy
Direct Identifier Examples (Name 3):
2.Medical Plan ID Number
3.Geographic subdivisions smaller than a State
-Street Address *
-City
-County
-Precinct
-Zip Code & their equivalent geocodes, except for the initial three digits
4.Birth Date*
5.Telephone numbers*
6.Social Security numbers (Last 4)
Whistleblower Protection Policy
It protects any employee who in good faith reports any instance of a violation of the company policy or laws from retaliation.
Why small talk is important
small talk in business settings is so important is because small talk allows people to be friendly at work without getting too personal.
Small talk is an important part of a conversation. It is the time when you build trust and create a bond.
Customer Service: Soft Skills
Active listening
Communication skills
Empathy
These are the common negative responses from phone agents when handling a confrontation.
Fight - getting angry back
Flight - Escaping (ending the call, transferring it, or placing the call on hold)
Freeze - Feeling intimidated
How May PHI May Used?
Employees may use or disclose PHI only for permitted uses without an individual’s specific written authorization.
How to Report Fraud, Waste, and Abuse (list at least 1 way)
Internally – Clark Resources
Externally – Health Partners Plans
Phone
Compliance Hotline: 1-866-477-4848
Special Investigations Unit: 1-866-HPSIU4U (1-866-477-4848)
First, ask open-ended questions
Second, practice active listening.
Third, show your enthusiasm
What are 5 P’s of Phone etiquette?
Be Prepared Be Professional
Be Patient Be Personable
Be Proactive