Healthcare payors and providers are under pressure to deliver exceptional experiences in a highly complex regulatory environment. Agencies in the United States like the Centers for Medicare & Medicaid Services (CMS) and Department of Health and Human Services (HHS), have made it clear: non-compliance has serious financial consequences. How do you balance both?
Regulations impact ratings
CMS has intensified its focus on fraud prevention, while HHS tightens oversight of HIPAA regulations and data privacy. Programs like Medicare Star Ratings and Medicaid Managed Care audits directly tie reimbursements to performance on quality metrics. That means providers must improve HEDIS scores to boost Star Ratings. Low performance leads to reduced payments, corrective action plans or loss of contracts.
Adding to the challenge, Medicare’s “pay and chase” model — paying upfront and recovering funds later in cases of fraud or non-compliance — forces payors to get things right from the start. In 2024, CMS recovered over $54 billion in improper Medicare payments and more than $31 billion for Medicaid. The vast majority of issues were often due to missed administrative steps. “79.11% were the result of insufficient documentation.”
A customer issue is a compliance issue
Seems simple enough. Get paperwork in order. But compliance failures aren’t always obvious, and they often manifest as seemingly simple patient complaints or service delays.
When members say, “I can’t find a provider,” “No one called me back” or “The automated system didn’t help,” it often points to deeper compliance gaps. If a member misses a screening or gives up trying to schedule an appointment, compliance can be in jeopardy potentially falling on the provider first, but eventually the plan.
"Patients shouldn't have to become experts in healthcare regulations just to access care and manage the coverage they need,” says Celeste Roman, Director of Compliance, TaskUs. “It's up to providers and payors to build trust, simplify the process and guide them through the complexity."
Technology can help streamline support, but while digital systems improve process efficiency and record accuracy, they can’t conduct empathetic interactions.
Imagine a senior citizen struggling to navigate digital tools just to schedule a check-up. Older populations, needing more frequent care are often uncomfortable with technology.
"Medicare Advantage plans are directly impacted by patient satisfaction scores, negatively affecting revenue for the plan. The goal isn't to frustrate patients with over-reliance on technology, but to design workflows that are simple and intuitive,” Celeste explains. “Even with the best benefits, a poor experience with a provider in the network — whether it's rude staff or difficulty accessing care — can reflect poorly on the entire plan."
Balancing compliance and experience
Navigating the balance between strengthening compliance and elevating member experience requires a holistic approach. Celeste suggests, “Organizations must have strong, clear policies and procedures that are not only well-defined but also executable.”
She counts these three steps as fundamental:
- Training frontline staff not just on SOPs, but on why compliance matters and how it affects patient care and provider performance.
- Designing processes with empathy, especially for vulnerable populations. Accessibility, clear communication and human touchpoints are critical.
- Auditing and feedback loops to identify where compliance gaps impact patient experience and adjusting workflows accordingly.
Accomplishing all this, however, involves a lot of administrative work and resources.
How a services partner can help
By delegating administrative tasks to business processing outsourcing (BPO) partners, healthcare providers and payors can focus on what they do best: delivering quality care and designing top-notch services and benefits.
Partners offer the scale, talent and expertise that drive:
- Customer satisfaction: With expertise in outreach management and training for empathy, partners help streamline workflows and manage patient interactions effectively.
- Information access and front office support: Partner service teams can handle tasks like patient inquiries and scheduling. Outsourcing also provides access to advanced technology like AI that helps advocates access and provide accurate answers faster.
- Compliance integration: Third-party partners incorporate compliance requirements directly into workflows, minimizing risks and ensuring regulatory alignment. They’re also experts in identifying areas for improvement, providing actionable insights to identify compliance gaps and enhance performance.
The next wave of compliance
As patient expectations grow and empathy becomes central to care delivery, the role of a services partner is more critical. Like other industries ahead of it, healthcare is racing to integrate AI automation for certain tasks. Celeste emphasizes the need for a thoughtful approach that also includes humans.
“Empathy and compassion are going to be the No. 1 driver of whether AI becomes a valuable solution. Technology without people won’t work,” she says.
She urges organizations to think carefully about where and how to apply AI to avoid creating unintended friction: Will it decrease or increase complaints? Will it provide more information? Will it make employees faster, more knowledgeable and more robust?
“Imagine someone is sick, and AI isn't answering,” she points out. “Friction can lead to regulation.”
Ultimately, AI will bring speed and precision, but it can never replace the human touch. Success will depend on how effectively healthcare organizations integrate AI without losing sight of what matters most: the emotional and physical well-being of the populations they serve.
