Plan for the best … prepare for the worst.


Every year, payers struggle with managing high-profile tasks that eat away at their profits. 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 workflows.

Annual changes to the rules and regulations and the constantly moving target CMS creates wreak havoc on any process workflow. 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 benefit 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 workflow 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 workflow process should work and how departments should be communicating and aligned. The model is a guide to developing effective interdepartmental workflows maximizing communication, efficiencies 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.

The ICM model

In a typical health plan, product development and the actuaries design the plan benefits. Product works with marketing communications/creative services to create the collateral materials for the government programs and commercial plans. The plan benefit requirements are then vetted through internal compliance, moving clockwise around the wheel. IT, operations and customer service play a role in providing ancillary services such as data file feeds, website content, formulary, pharmacy and provider directories. The most important part of the wheel is the member in the middle. The member's experience is vital. Without a seamless ICM process workflow, the member's experience will be significantly impacted. Department staff will spend less time focusing on the experience and more time pointing fingers when deadlines are missed or timelines slip.

AEP should be a wake-up call. With an integrated workflow process that provides robust reporting capabilities, C-level executives know where member materials are in the process and they can pinpoint their risk. Most payers dread AEP. People burn out and payers miss opportunities to maximize technology. Haste and waste create poor plan designs, delays in template reviews and submissions, and an inability to reconcile member and provider data. I have watched plans use their ad agency to create evidence of coverage and annual notification of change documents (ANOC) at agency rates. I have seen non-healthcare project-management tools force-fitted only to be useless to the plan. Even great project-management tools are not designed to deal with health-plan rules and regulations.

I recommend employing a project-management system that encompasses the ICM model. There are five critical questions execs need to ask consultants or software vendors about their solution before hiring/purchasing them:

1. Can the system adapt to the payer environment and link all of the key departments?

2. Can it interface with other critical software applications without significant cost?

3. Is the system adaptable to the plan's workflow with Medicare, Medicaid and commercial plans?

4. Does the project-management system include templates and version tracking?

5. Is there a library for collateral management? Does it track versions so it can be used for internal and external audits?

Make a post-AEP resolution now. Blast open your ICM roadblocks. Use technology to get your members and providers what they need when they need it.


Debbie Mabari is CEO of Cody Consulting.
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