I am in the midst of helping to sell a family member’s house. The house was recently remodeled and looks amazing in the realtor posting. An offer came in for full asking price, and we are now in the inspection phase of the process. This is where things get real. The buyers have an “options clause,” which is an opportunity to walk away from the sale if things aren’t as they expected. One of the inspections showed some foundation damage that if not fixed will result in the sale falling through – and for good reason, as the buyers want a house in good working order.
The new Open Enrollment Period (OEP) that begins in January 2019 and allows Medicare Advantage members to elect another health plan between January 1 and March 31 is like an options clause at a health plan. If things aren’t as they were promised when they enrolled, members will have the option to walk away. Now more than ever, a health plan should make sure its processes are in excellent working order.
Here are five things to consider to ensure members don’t find anything wrong in your health plan’s foundation and end up exercising their OEP options clause:
- Have your Operations teams review your post-sales leave-behinds. Many health plans now have a leave-behind for their new enrollees outlining what to expect in the first few weeks after their application is received. If your Operations team hasn’t reviewed it lately, or at all, now is the time. This allows your team to verify the details are accurate and reminds the team of the member’s expectations.
- Make sure your provider data is both adequate and accurate. The results of the Centers for Medicare & Medicaid Services (CMS) Provider Directory Review show dismal results. The Customer Service team at your health plan may have been telling you there was a problem for years, and now the industry has backup data documenting a huge industry gap. Your enrollees have a fundamental need to understand who is and isn’t in your networks when they join your plan. In the past, members who went to their first doctor’s appointment only to find out their provider wasn’t really in network were still typically locked into your program until the next Annual Election Period. Not so anymore. Those members can leave your plan for another during the OEP. If the CMS Provider Director Review and your Customer Service staff concerns didn’t motivate your plan to take provider directory accuracy seriously, the future loss of revenue when members disenroll should.
- Refine member experience in your enrollment processes. Recent years have allowed a lot of automation in the enrollment process. Currently, health plans talk auto-adjudication rates for their enrollment processing. Just make sure you didn’t go too far into automation. Do you have any outbound calls to obtain missing information? If not, consider changing that. It would be unfortunate to spend hundreds of dollars to acquire a new member only to let them slip through the cracks because the health plan only mails letters to obtain missing information. Similarly, how is your primary care physician (PCP) matching logic working? If your plan can’t automatically match the provider, is a PCP assigned? This is great for automation but lousy for customer service and first member experiences. It’s time to review your enrollment processes to make sure they are member centric and a positive first touch.
- Validate your benefit configuration and claims payment processes. Along with provider access, paying members’ claims correctly is a fundamental obligation of every health plan. When was the last time you verified all your benefits and member cost shares were processing correctly? What is your claims development process? If something is denied, how clear is your denial language? Invest the time this year to validate these processes. If your new members experience problems with their first claims payments, they will soon have an escape route through the OEP.
- Educate and empower Customer Service. Customer service is harder today than anytime in past history. Health plan Customer Service Representatives (CSRs) are required to know and manage a confusing maze of topics with sometimes angry or distraught members. Some plans have built-in scripts and tools to help direct the call, which can be a lifesaver to the CSRs taking the calls. They can equally be a barrier to connecting to members they are helping. One of the best ways to support CSRs and help them connect with your members is to give them what they need to solve problems. Do they know who to go to when a member calls wanting a service, or does your plan not have a clear member organization determination request process? If members are having difficulty obtaining their prescriptions, is there a method to transfer them to the correct person to resolve the issue now? Are member communications going out and CSRs have no knowledge of the information, and, therefore, the member has to read the letter to them, so they know what is going on in order to assist the member? It’s time for a sit down with Customer Service to understand how we can support them in providing top-notch service.
The OEP is a game-changer in many ways. It far surpasses the past annual disenrollment period as members can now exercise their option to choose another health plan throughout the first quarter. This gives members an opportunity to really try out your plan, kick the tires, so to speak, and see if it delivers on what was sold to them. Now, more than ever, it is critical you make sure you deliver the value you promised. If not, it truly will be your plan’s loss.
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