AUTHOR: CRAIG KASTEN, CEO and Managing Partner
Look up the headquarters or regional offices of most large and mid-size insurance companies on Google Earth and what are you likely to find? Sprawling, well-manicured campuses with several multi-story buildings that house thousands of employees, acres of call centers and a labyrinth of massive file rooms archiving mountains of incoming paper documents.
Despite all of the advances in technology over the past 20-30 years, most insurance companies are still conducting business the way they did in the 1950s. Sure, laptops have replaced typewriters, call centers are managed with slick applications and other individual technologies have been introduced. But the processes – from the way they onboard members to the way they take in and adjudicate claims to the way interact with providers and members – remain largely unchanged. All those buildings and all those employees are required because their businesses still rely primarily on armies of workers performing manual tasks.
That may be the past and the present. But it is not the future. Instead, the insurance company of tomorrow will live largely in cyberspace. Those armies of employees will be replaced by automation, driven by new technologies that increase efficiency, lower costs and deliver superior customer service.
It’s a transition that must be made. The Affordable Care Act (ACA) has introduced the first of many changes to come to the health benefits landscape – not the least of which is making an additional 30 million Americans eligible for health insurance. While a positive for the nation’s health, as enrollment expands it will place significant pressure on outdated, manual health benefits administration processes. We are seeing this occur already, especially around customer service. Health payers that cannot service members with the speed and accuracy those members expect will have difficulty retaining them during the next enrollment period.
Expanding access to care at an affordable cost is a daunting challenge that cannot be met by taking a single step or simply adding a new web portal. It requires a concentrated effort to take advantage of new approaches and technologies. In addition, health payers must learn to think differently. Rather than throwing bodies at problems, as they have in the past, they need to take a long, hard look at where they can use automation and which areas absolutely require human evaluation.
So, what does the future hold for benefit administrators and health plans? Specific innovations in benefits administration software are available today that pave the way and supply a technological framework to evolve their operations from one that requires those large, spacious campuses to one primarily based in cyberspace.
A simple, straightforward game plan to make this transition includes:
- Deployment of robust web portals to meet member and provider expectations. Through their interactions with retailers, telco companies, technology providers and other industries, consumers have become conditioned to using a web-based, self-service portal rather than waiting in a phone queue for a customer service representative. They can go online to obtain information or complete transactions whenever they want from wherever they are – even from their smartphone or tablet. Benefits administrators and health plans must make this same level of self-service available to their members and providers rather than communicating only by phone, email or regular mail. Members should be able to search for a provider, check benefits eligibility, look up progress against deductibles, add family members to a plan, download membership cards and more without having to contact a customer service representative and wait for answers. Similarly, providers should be able to submit claims, review payment status, confirm member eligibility, submit documentation such as X-rays and perform other common actions through a portal. By providing most answers through online self-service portals, payers can focus call center personnel on answering more difficult, complex questions that provide higher value to members and payers while reducing their costs to deliver that level of service.
- 24/7 online claims administration. Most benefits administrators and health plans cannot afford the high level of overhead required to staff claims processing or authorization departments around the clock. That means claims or requests for authorization submitted after working hours must wait until the next day –or longer – to be reviewed. By implementing online claims administration technology, benefits administrators and health plans can offer continuous, 24/7 processing of incoming claims and authorizations to remove the delays and deliver resolution faster. These technologies also offer the ability to isolate certain exceptions and pass them to the appropriate personnel for immediate review on a 24/7 basis, ensuring they receive the proper level of attention rather than getting “lost in the shuffle” of paperwork.
- An automated claims administration process. Today, despite advances in technology such as electronic data interchange (EDI), much of the work of processing claims and authorizations remains mired in manual tasks. Even if data is submitted electronically, the actual processing often requires human intervention – which can cause significant delays if the staff is suddenly inundated with claims. New innovations, however, are replacing these manual tasks with automated, rules-based technologies that will quickly and accurately process 100 percent of all claims edits, and provide immediate authorization for certain agreed-upon services without the need for the provider to call the payer first. Recently-introduced technology is even enabling providers to process a prospective benefit claim to determine the reimbursement levels and compute the corresponding patient responsibility for each prospective service in real time. In addition to their use with standard fee-for-service processing, these technologies are helping payers prepare for the future by enabling the administrations of the new bundled payment formulas that are essential to containing spiraling healthcare costs. An administration software platform that manages these complex reimbursement arrangements helps change the often-contentious relationship between providers and payers into one that is more of a partnership. It also reduces the number of claims experts required, helping bring down costs as it speeds the process.
- Paperless claims administration. Maintaining paper files is both expensive and inefficient. New imaging technology and database designs are eliminating the need for massive farms of file cabinets (and the real estate required to house them), replacing them with electronic files that can be securely stored in a fraction of the space, either on-premise or in the cloud. Converting paper to electronic files makes the data easy to access 24/7 from anywhere in the world; no need to call a co-worker in another office to ask them to pull the file. It also makes the information easily searchable, saving hours of time over looking through drawers of paper files – especially for files that have been misplaced. And, best practices require the implementation of disaster recovery/business continuity plans. Should a fire, flood, hurricane, explosion or some other catastrophic event occur, a backup or archived copy ensures that no data is lost. Not so with paper files.
- Promote operational transparency through performance dashboards. Filterable, online access to real-time dashboards delivers greater visibility into financial operations. Unlike many spreadsheet-based reports, these dashboards are driven by powerful performance data analysis engines that offer complete operational transparency. This information helps benefits administrators and health plans monitor key performance indicators, allowing them to improve business efficiency, solve problems and streamline the delivery of benefits. The result is a payer that is better-prepared to win in an increasingly competitive market.
This vision is very different from the way payers operate today. But it is essential not just to surviving but thriving in the future.
To get from where they are now to there, health plans must begin to fully exploit these emerging technologies as soon as possible – especially if they want to take advantage of the potential influx of seven million new members the ACA offers. Delivering better healthcare to more people at a lower cost is the key, and implementing and realizing the benefits of cyberspace’s benefits administration innovations will play a key role in accomplishing that. The sooner the better for everyone involved in our healthcare ecosystem.