Why Is Quality

Important?

What does Quality mean to you?

Worldclass?!
Excellence?!
Perfection?!
Efficiency?!

Purpose of the Quality Program

Focus on the Customer

Know your customer

Provide more specific and actionable

feedback to agents.

Define your customers (callers)

Focus on our Customers

The Big Three

Never
compromise. We
deliver on our
promises, have
the courage to
acknowledge
mistakes and do
whatever is
needed to fix
them.

Walk in the
shoes of the
people we serve.
Be compassionate
and
understanding so
you can feel and
identify with their
needs.

Build trust
through
collaboration.
Approach people
with respect,
humility,
confidence and
energy.

Focus on Compliance
When we are accountable, we earn the trust our
members, providers and business partners place
in us.
Focus on the Process
Consistently deliver high quality and superior
results that make a difference.

Compliance Focus
Verification & Privacy

Did the agent follow the verification and

privacy requirements?

ompliance Focus
Business
Requirements

Did the agent appropriately

identify and classify the issue?

Did the agent follow the correct

policy?

Did the agent follow mandated

(internal, client driven
policies?

Process Focus
Documentation
Was the documentation process followed?

Commitments
Were the commitment requirements followed?
Internal
Procedu
re

Quali
ty
System
Utilizati
on

y is Building Trust Important?

Establish the caller faith that

you can resolve their issue
Strengthens our
relationship with our client
and customers
Provides a declaration that
we are here to help with
their individual
Creates an atmosphere of
equality, not inferiority,
between parties

Issue Resolution

Was the issue handed off correctly?

Was correct and

complete solution
provided?

hy is Accurate Information Important?

Increased customer
satisfaction and loyalty
Customer has a better
understanding of
information
Decreased escalated
calls
Customers issue is
resolved on their first
call

ssue Handed Off Correctly

Examples of what is reviewed:

Was the
Did the
Was the
call
Did the
agent give
correct
transferred
agent
the caller
protocol to the area
escalate a the correct
per
that can
call when phone or
situation resolve the
necessary?
fax
followed?
callers
number?
issue?

Process Focus

Documenta
tion

Commitme
nts

Internal
Procedures

System
Utilization

Was thedocumentation process followed?

Were the commitment requirements followed?

Did the individual comply with internal

procedures?

Were the systems/tools utilized or able to be

utilized effectively and efficiently?

Questions

Quality Standard Operating Procedure

Objectives: To be able to define the sampling methodology
with regards to (add business requirements)
Background: Establish a standard process for sampling and appeals

SAMPLING METHODOLOGY

Step 1- Standard Quality Programs

Quality audits are

currently
completed on a
monthly basis
for a variety of
sample types for
both the calls and
claims businesses.

Performance
guarantee reviews

to represent how each

policy is performing
vis--vis our

Individual audits
to represent how each
of the individuals
within the
business is
performing

Corporate audits
to represent how the
business is
performing

Step 2- Sample Size - Claims

Corporate Audits Basis

the precision limit, total
volumes processed and
past accuracy
performance, the sample
size for this sample was
arrived at 84 claims per
month for 2016. This will
be reviewed every year in
the month of December.

Performance Guarantee
Audits Per BPQM
standards, the sample
size is fixed at 40 claims
per group per month. The
endeavor in 2016 will be
to move this sample to a
random stratified sample.

Individual Audits A
random sample of one
claim per working day per
processor will be sampled
per month.

Step 2 (a)- Sample Size Processor on PTO for 3 orClaims

less than 3 days will also have 21 audits per month (Samples to complete the 21
audits will be picked from the days when the processor was present.)

Processor on PTO more than 3 days sample will reduce based on working days. (e.g. 17 working days (4
PTO)=17 audits)

Processor not on PTO and doing OT (Saturday or Sunday) will have sample size increased based on # of
working days. (e.g. 21 working days+ 4 OT=25 audits)

Processor on PTO for more than 3 days and also did OT (Saturday Sunday) will have sample size changed
based on # of working days. (e.g. 17 working days (4 PTO) +4 OT=21 audits).

Step 2 (b)- Sample Size - Calls

Corporate Audits Since there was no data available to gauge past performance, a
sample size of 50 claims was determined for this sample for Q1 and Q2 of (enter year).
This will be reviewed and revised in Q3 based on the available performance data

Performance Guarantee Audits Per BPQM standards, the sample size is fixed at 25
audits per group per month
Individual Audits A random sample of 8 audits per month per agent will be sampled.

Vendor/TPA Quarterly Audits A random 100 audits/ month will be evaluated to

showcase the Wipro Call Audits.

Defect sent to processor/

Supervisor via SharePoint

If agreed get it
corrected by processor
& close the issue as
error. (Close it on
SharePoint)
If disagreed 1st Level
Processor/Supervisor
will file appeal via
SharePoint.

Receives appeal determination

If agreed, remove the

defect & send the reply
to processor/supervisor
via SharePoint.

If disagreed and the

defects were correct
auditor will provide
additional information
in support of the defect
via SharePoint.

APPEALS PROCESS MAP

If transaction again
disagree get it corrected by
processor/ close the issue
as error.

Auditor will Re-review the error and

supporting documentation in comparison to
original scoring

If agrees get it corrected by

processor/ close the issue as
error. (Close it on
SharePoint)
If disagreed 2nd Level - SME/
Ops Sups will respond via
SharePoint with supporting
document/or defect to be
discussed on weekly Quality
Call.

For Claim Quality: - Final

decision would be with
the Sr. Quality Manager
irrespective of the
sample type.
For Call Quality: The
Final decision would lie
upon (enter contact)

Reporting/Calls & Claims

Formatting of reports, frequency and

Dashboards are one of the most important
owner.
management tools available for managing
performance and progress toward business goals.
Dashboards can be designed and used across a
wide range of objectives, from monitoring an
organization's global business strategy, to
measuring the ability of a department achieve
service-level targets.

Dashboard to be sent
out twice in a week.

Dashboard will
showcase the
performance of the
auditors.

SLAs for Calls and

Claims

Overvie
w

Performance Guarantee Audits

Provide a measure of performance for policyspecific statistics.
Optional audit offered to policies to provide
individualized results separate from other reviews.
Identify opportunities for policy-level improvement.

Calls Quality
SLA Policies

Claims Quality
SLA Policies

Add Call SLAS

(usually
group/client
driven)

Add Claim SLAS

(usually
group/client
driven)

Contact
Enter Contact

Hope you have a Quality-Proof day