Brown and Toland — Customer Service Playbook

Executive summary

Brown and Toland’s customer service function must balance clinical sensitivity, regulatory compliance, and consumer experience. This document outlines practical, measurable steps to operate a best-in-class patient/member service organization: staffing models, contact channels, KPIs, escalation paths, security requirements, and realistic budgets and timelines for upgrades. The recommendations reflect industry norms for physician networks and health-plan-facing customer service operations.

Goals: achieve a 90th-percentile phone response time under 5 minutes, email response <24 hours, first-contact resolution ≥80%, and Net Promoter Score (NPS) ≥50 within 18 months of restructuring. The playbook is actionable: it includes suggested shift patterns, sample tech stack components, compliance touchpoints, cost ranges, and escalation matrices.

Operational scope and hours

Define the customer service scope up front: appointment scheduling, benefit verification, billing inquiries, referral coordination, clinical triage, provider complaints, and provider-relations intake. Separate functions into “member-facing” and “provider-facing” teams to reduce complexity and average handle time; cross-train 15–20% of staff for overflow coverage. For a network size of 50,000–150,000 members, a baseline ratio of 1 service agent per 1,000–1,500 active members is typical.

Hours should match member needs: core hours Monday–Friday 8:00–17:00 PST with extended evening coverage to 20:00 on weekdays and 9:00–13:00 on Saturdays. Maintain a dedicated 24/7 nurse advice line for urgent clinical triage. Expected volume modeling: plan for peak call volume during 8:30–10:30 and 13:00–15:00; staff peaks to keep average speed of answer under 120 seconds and abandonment rate below 5%.

Contact channels (essential)

• Phone: Primary inbound line with IVR and queueing. Target SLA: answer 80% of calls within 120s. Example provisioning: (415) 555-0100 as your published main line; use local area code for member recognition.
• Email: Secure inboxs for non-urgent inquiries with case-routing and auto-reply containing a ticket number. SLA: first response within 24 hours; closure within 3 business days for standard requests.
• Portal & Secure Messaging: Integrate with member portal for appointment confirmations, lab access, and secure messages (HIPAA-compliant). Response SLA: 24–48 hours during business days.
• Live chat / SMS: Implement SMS confirmations and an optional chat widget for quick triage. Limit SMS to administrative communications unless enrolled in secure-messaging workflows.
• Provider relations line: Dedicated phone/email for provider offices to resolve credentialing, referrals, and contracts; target 48-hour turnaround for non-urgent requests.

Each channel should sync into a single CRM/OMS so cases created via phone, email, or portal are visible in one record. Recommended timeline: consolidate channels onto a unified platform within 6–12 months; typical project cost range $75,000–$350,000 depending on integrations and vendor (cloud CRM + telephony + secure messaging).

KPIs, reporting and service levels

• Phone: 80% calls answered within 120s; abandonment rate <5%; average handle time 6–12 minutes depending on complexity.
• Email/Portal: 95% first-response within 24 hours; average resolution under 3 business days for routine issues.
• Quality: First-contact resolution ≥80%; CSAT target ≥4.5/5 and NPS ≥50 within 12–18 months post-improvement.
• Compliance & Security: 100% of patient communications handled on HIPAA-compliant channels; audit logging retained for minimum 6 years per HIPAA requirements.

Set daily dashboards and weekly trend reports. Include root-cause analysis monthly for top 10 complaint themes (billing, scheduling, prior authorization, referral denials). Use automated alerts when KPIs degrade >10% week-over-week. Budget a small analytics team (1 FTE analyst per 4–6 supervisors) to run continuous improvement and to validate vendor SLAs.

Staffing, training and quality assurance

Staffing: Use a tiered model—Level 1 handles scheduling/billing verification, Level 2 handles eligibility/prior authorization, Level 3 escalates clinical questions to nurse or medical director. For 100,000 members, estimate 40–60 FTEs across all shifts: 25–35 member-service agents, 6–10 provider-relations, 4–6 nurses, plus supervisors and QA staff.

Training: New-hire ramp of 4–6 weeks with blended learning (e-learning modules + supervised live calls). Mandatory certifications: HIPAA refresher every 12 months, privacy/security training quarterly for high-risk roles. Create a 6-week competency checklist with 20 core workflows (eligibility, claims filing, appeal steps, referral process, patient privacy). Maintain a knowledge base with timestamps and version control; update clinical or billing workflows within 48–72 hours when policy changes occur.

Escalation, compliance and clinical governance

Escalation matrix: Tiered SLAs — urgent clinical escalations routed within 30 minutes to a nurse triage line; high-impact billing/denial escalations assigned to a specialist with a 2-business-day resolution target. Maintain a clear RACI (Responsible, Accountable, Consulted, Informed) for all escalation types and publish it internally and to provider partners.

Compliance: All systems must support HIPAA controls (access logging, role-based access, encryption at rest and in transit—recommend TLS 1.2+ and AES-256). Retain logs and documentation for at least 6 years. Perform annual third-party security attestations (SOC 2 Type II or equivalent) and quarterly vulnerability scans. Clinical governance requires a medical director to review adverse patient experience cases weekly.

Technology, budgets and timelines

Technology stack: cloud telephony with SIP trunking, omnichannel CRM (e.g., Salesforce Health Cloud or equivalent), EHR/portal integration via HL7/FHIR APIs, secure messaging vendor, and reporting/BI tool. Budget guide: initial implementation $100k–$400k; annual SaaS/licensing $30k–$150k depending on scale and modules. Allow 3–9 months for vendor selection and phased rollouts, with pilot to a single line of business for 6–8 weeks.

Vendor procurement: require HIPAA BAAs, uptime guarantees ≥99.9%, and disaster recovery RTO/RPO commitments. Prototype integrations and a data-mapping exercise should cost 10–15% of total project budget and reduce downstream remediation by >30%.

Practical next steps

1) Conduct a 2-week volume and root-cause study to validate staffing ratios and peak patterns. 2) Select an omnichannel CRM with vendor references in healthcare and a shorter list of 3 vendors. 3) Pilot a 6-week training cohort and measure CSAT, FCR, and AHT baseline to demonstrate lift. Expect to see measurable KPI improvements within 3 months of go-live and reach target SLAs in 12–18 months with continuous optimization.

For governance and ongoing improvement, publish a monthly service review with trending KPIs, complaint root causes, and a one-page action plan prioritized by impact and ease of implementation. This keeps leadership visibility and supports budgeting for further investments in automation (IVR deflection, chatbots for administrative tasks) over the following 12–24 months.

What is the phone number for Brown and Toland provider claims?

(415) 972-6002
Contracted Brown & Toland providers may initiate a claims inquiry/reconsideration request by doing one of the following: 1) Contacting Brown & Toland’s Claims Customer Service Department by calling: (415) 972-6002.

Are Brown and Toland part of Sutter Health?

With the addition of Brown & Toland, a total of six IPAs are now in the Sutter Medical Network. The network also includes five medical foundations owned by Sutter Health, and other medical groups, totaling nearly 5,000 physicians participating.

What is the controversy with Sutter Health?

Sutter Health has agreed to settle a massive class-action lawsuit accusing the nonprofit health system of illegally wielding its market power to drive up Californians’ health care costs by more than $400 million. The long-running federal lawsuit was settled on the eve of trial on Sunday.

Is Brown and Toland leaving Sutter Health?

We have recently been made aware of a contract termination between Sutter Health Plus HMO and Brown & Toland Physicians Medical Group effective January 1,2021.

Who bought Brown and Toland?

Sheppard Mullin represented Blue Shield of California, one of the largest health plans in California, and Altais and Altais Clinical Services (ACS) in ACS’s acquisition of Brown & Toland Medical Group and its affiliated entities (Brown & Toland), a network of more than 2,700 physicians serving more than 350,000 …

Does UCSF accept Brown and Toland?

If you are a member of a preferred provider organization (PPO) plan that is contracted with UCSF, you can see a UCSF doctor without selecting Hill Physicians as your medical group. UCSF is not an in network provider for Brown & Toland Physicians patients.