From enrollment to improving member health

Health plan leaders are at a crossroads today. The growing prevalence of value-based care, innovative entrants setting new standards for market readiness, evolving regulatory requirements, and patient behaviors influenced by retail experiences are bringing a tidal wave of transformation to the care continuum. 

Concerns about staffing shortages, challenges in technology adoption, and healthcare financing, along with the estimated rise in Medicare Advantage enrollment to 62% by 2033, present a unique challenge to operational leaders who must effectively deal with a constantly evolving ecosystem while facing economic pressures to do more with less. 

With healthcare spend set to hit $6.2 trillion by 2028, health plan leaders must embrace digital transformation initiatives and integrated platforms as a strategic imperative and not just an ideal state. Digital technology is a cornerstone in streamlining operations and driving efficiency, changing how Payers deliver healthcare. 

Understanding the operational challenges in health plans

The rise in mega-mergers between cross-regional super health companies, increased regulatory complexities among government health programs, and roadblocks in growth/shift trajectory from fully insured to self-funded plans   make for some of the pressing issues faced by health plan providers.  

• Complex claims billing and reimbursement: From the Affordable Care Act (ACA) and Medicare billing to small group insured products, managing reimbursement rates, contracts, and claims processing across a diverse payer mix is tough. Furthermore, plan providers face double pressure – skyrocketing medical costs on one side and maintaining affordable premiums to bolster provider networks and member benefits on the other. And if that wasn’t enough, detecting and preventing fraudulent claims poses an additional critical challenge. 
• Claim denials: Navigating intricate claim processing rules and addressing provider errors, such as incorrect coding or missing documentation, contributes to   high denial and rejection rates. Variations in claim processing guidelines across different payers further complicate the process. Efficiently managing the appeals process is crucial to recovering denied claims and improving cash flow. How should you ensure that the claims control you have put in place prevents waste and abuse as opposed to merely creating provider or member frustration?
• Operational and data management silos: Because of the complexities that exist in healthcare delivery, effective cross-departmental communication is critical. Inaccurate, inconsistent, or missing data leads to poor outcomes. Ensuring effective collaboration between sales, provider relations, operations, providers, and members is a key differentiator between an effective health plan and one that is struggling.
• Regulatory compliance: Healthcare delivery is one of the most regulated areas of our economy. Constantly evolving federal and state healthcare laws and regulations pose unique challenges for health plan operators. The carrier must be completely aware of the expectations of the regulator and how meeting those regulations will affect current processes. In many cases, a health plan that depends on legacy systems may be forced to meet its regulatory obligations through manual processing. This can prove to be very costly and increase the risk to quality and timeliness.

Such complexities can impact care, organizational resilience, and the overall effectiveness of healthcare systems. The most sophisticated approach to this involves not only meeting the mandate but determining how to use the mandate to improve the experience of the health plan members.

Examples of new technologies being used to improve operations.

Health plans can significantly enhance operations by adopting advanced technologies:

• Artificial intelligence (AI): AI is being used to reduce the complexity of data and rule-intensive health insurance processes by searching for data anomalies and detecting potential errors. It can also monitor claims reconciliation and pinpoint inconsistencies with unparalleled precision, enhancing the credibility of core claim systems.
  
  
• Internet of Things (IoT): IoT wearables on members can help health plan providers track, monitor, and analyze data based on lifestyle, nutrition, and medical history. Incentivized policies can encourage members to reduce health expenditures. For example, in exchange for a specific number of steps walked every day, the member would be entitled to a discount on their premium.   
  
  
• Robotic Process Automation (RPA): RPA can handle high-volume, repetitive processes, increasing efficiency and reducing errors. Automating routine tasks like data entry, claims adjudication, and eligibility verification produces dependable results while freeing up staff to focus on more complex issues and tasks that improve the relationship with a health plan’s members. 
  
  
• Natural Language Processing (NLP): NLP can extract information from sources such as medical records, benefit summaries, claims narratives, and clinical guidelines, giving valuable insights for enhanced decision-making. One of the areas that shows the greatest promise is in supporting Member and Provider Customer Service, allowing the effective summarization of massive amounts of data to aid in answering members’ and provider’s questions.
  
  
• Digitalization: This is focused on making the data necessary to drive better decisions available. Whether it’s health records, claims, or benefit summaries, ensuring the availability and dependability of this data by converting them into digitized formats improves accessibility, reduces storage costs, and leads to improved data-driven insights. This seamless information sharing between providers and payers can be further enhanced through the integration of health platforms that help manage diverse health programs.