Member services for a United States regional health plan

The client is a regional health plan in the south-western United States covering approximately 920,000 members across commercial, marketplace and Medicare Advantage lines. Member services handles benefit enquiries, claims status, provider network questions and prior authorisation status. Roughly a quarter of membership is Spanish-speaking.

Member services performance had degraded to a level attracting regulatory attention. Average speed of answer stood at 402 seconds. Annual enrolment abandonment exceeded 30%. The plan had received complaints escalated through state channels, and its Medicare Advantage star ratings exposure on member-experience measures had become a board-level concern with direct revenue consequences.

Repeat contacts consumed a large share of capacity, with roughly 38% of claims-status enquiries being repeats from members who had received an incomplete answer.

The compliance dimension constrained options. Member services handles protected health information, and the plan's prior offshore experience had produced an internal audit finding on access controls that made its compliance function resistant to any offshore proposal.

Onshore expansion was not affordable at the required scale without breaching the plan's administrative expense ratio.

Corpshore Mexico was selected after a compliance-led evaluation in which the plan's privacy officer participated from the first meeting. The material factors were the documented HIPAA-aligned control environment, the Toronto parent governance providing a North American contracting counterparty and Corpshore's acceptance of a right-to-audit clause with on-site inspection in Mexico City.

Nearshore geography carried independent weight. A direct flight of a few hours from the south-western United States made physical audit practical, and Mexico's integration with the US under the USMCA framework gave the plan's legal team a familiar commercial footing. The privacy officer has since conducted two on-site reviews.

Ninety-two agents in Mexico City: 70 English-primary and 22 Spanish-bilingual, with eight team leaders, three QA analysts and a dedicated compliance lead reporting functionally to the plan's privacy officer. Coverage runs 08:00 to 20:00 across US time zones Monday to Friday with extended weekend hours during annual enrolment, scaling to 128 agents for enrolment. Work is performed in a physically segregated area with clean-desk enforcement, no personal devices and session-level access logging.

Attack repeat contacts, not queue time. Average speed of answer was the symptom; repeat contacts were a substantial part of the cause. The first intervention targeted resolution completeness on claims status.

Complete-answer protocol. Agents were trained and measured on providing a complete disposition, what the status is, why, what happens next and by when, rather than reading a code. Quality scoring was rebuilt around completeness.

Compliance as an operating discipline. The dedicated compliance lead runs monthly control review, quarterly access recertification and a documented incident protocol.

Enrolment surge as a planned event. Annual enrolment capacity is planned from July, trained by September and live in October, drawn from a returning pool where possible.

Average speed of answer fell from 402 seconds to 58 seconds by month 12. Annual enrolment abandonment fell from over 30% to 6.0% in the first enrolment period under the engagement.

Repeat contact rate on claims status fell from 38% to 12%, which the plan identifies as the primary driver of the queue improvement.

The plan recorded no HIPAA-related audit findings against the Corpshore operation across two review cycles.