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Health Plan Interfacing Health plan interface issues Plan for the best … prepare for the worst. By Debbie Mabari E


very year, payers struggle with managing high-profi le tasks that eat away at their profi ts. Challenges with annual enrollment (AEP), new government rules, data issues and low HEDIS scores drain resources.


With health plans growing, changes to Medicare, Medicaid and healthcare exchanges, payers are facing many challenges communicating to members and managing interdepartmental process workfl ows.


Annual changes to the rules and regulations and the constantly moving target CMS creates wreak havoc on any process workfl ow. Without a succinct strategy, payers are at risk. CMS violations can cause monetary penalties and unnecessary work responding to last-minute audit requests. New CMS rules that require plans to upgrade benefi t coverage information to all members and prospects can be suffocating.


How can payers better manage this process? My best advice: Plan for the best and prepare for the worst. In my years of working and consulting at health plans, most C-level execs don’t understand the process workfl ow of their own organization – even at a high level. Understanding how departments interact with one another allows senior managers to make positive changes. Surprisingly enough, 90 percent of payers face the same challenges no matter their size. It’s true. The Integrated Collateral Management model (see diagram below) explains how the workfl ow process should work and how departments should be communicating and aligned. The model is a guide to developing effective interdepartmental workfl ows maximizing communication, effi ciencies and high-level insights. As a CEO, I ask the same question you do: “Why do I need to get into the weeds?” In today’s economy, the weeds are considered low-hanging fruit.


Intergrated Collateral Management TM Feedback


Product/LOB Group, Individual, Government


Members & Prospects


Customer Service


Web Viewing and Adhoc POD & Fulfi ll


Lang. Trans. Workfl ow Design & Content Input Web Storefront


Enterprise Portal


Pre and Past-enrollment, Direct Mail, Prospectus, Web, Brochures, etc.


Web POD,


Members & Prospects


Operations


Collateral Date and


Print Streams


Document and Data Feeds


Template Dev., Composition, Data Mgt.


IT and App Dev.


Regulatory Content Mgt.


Compliance


Design & Content Mgt. Brand Management Web Storefront


Document and Content Design


Regulatory CMS


Collateral Requirements MarCom


Members & Prospects


24 December 2011


HEALTH MANAGEMENT TECHNOLOGY


www.healthmgttech.com


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