My father was hospitalized a few years ago and then readmitted a few days later. A few weeks later when I was checking in with him, he told me he had to change insurance companies. When I asked what was up, as I thought he was satisfied, he said he owed $36,000 for his hospital admission, and his insurance was worthless. Knowing that couldn’t be the case, I asked why he thought that. He showed me his Explanation of Benefits (EOB), which did indeed show a denial of his inpatient admission with a total billed charge in excess of $36,000. The EOB denial message indicated the provider would indicate the amount the member owed. I was shocked but knew there was no reason for the denial, so we called the insurance company. The Customer Service representative explained there was disagreement over whether the visit should have been billed as observation or an admission, but that didn’t involve my dad. We were told to disregard the EOB. I explained what was happening to my dad, and he ended up staying with the plan as, despite this bump in the road, they were a good fit for him. I was never the less frustrated that on top of two hospitalizations, he had to deal with the stress of a large hospital bill because of unclear EOB language. It should be each of our goals to prevent this type of scare.
This year, there is even more reason to ensure these things don’t occur. The Open Enrollment Period (OEP) is going to allow members to make a change from January 1 to March 31. Do you know what hidden bumps in the road your plan has that could result in disgruntled members and potential disenrollments?
Here are some things to look into before January 1:
- Know Your Operations Member Touch Points. Some operations functions are member facing, such as customer service. Many operations functions are back-office actions. Sometimes we overlook how these functions impact members and the influence those actions have. If an application is received and is incomplete, does the enrollment team place a call to the member or agent to attempt to resolve the issue or, instead, mail the Centers for Medicare & Medicaid Services (CMS)-required letter? Do you auto-assign or work with the member to identify or select a primary care physician (PCP)? If a member has a denied organization determination, do you ever outreach to the member to discuss his or her options and the appeal process? Is your EOB language clear on what action the member needs to take and the ultimate outcome? Have you updated your scripts and talking points for new guidance in 2019 such as Dual Eligible and Low Income Subsidy (LIS) special election changes?
- Evaluate Productivity versus Member Experience. Health plans should ensure systems are set up to handle approved processes with minimal, if any, touch points. Auto-adjudication isn’t just for claims anymore. How many of your applications auto-adjudicate through the system? We recently worked with a client that has to touch every electronic or telephonic application in the enrollment system to update the title field (Mr./Mrs./Miss). Time should be freed up to invest in the areas that need a member touch. Actions that welcome members or retain members should have as many personal touches as possible. Sometimes we find automation in the wrong areas. What is the process in place to manage PCP mismatches for new applicants? Some plans still auto-assign first and member outreach only if there is time. Is there a mechanism to involve provider contracting when members select non-contracted providers as their PCP to complete a contracting attempt? What about a step to ensure the provider directory is accurate? These types of actions should be built into production time frames to ensure top-level customer care from all areas of the organization. How tragic to spend all that money to get a new member only to upset him or her with the very first action.
- Mitigate Those Trouble Spots. Do you know what your plan’s top trouble spots impacting members are? I am betting Customer Service and Appeals & Grievances could list them off. If you don’t have that list and are not actively working to mitigate those issues, gather it now. You still have time to impact 2019 and prevent members from leaving the plan as it doesn’t match their expectations. Oftentimes trends are identified, but the root cause and mitigation steps are missed in the crush of day-to-day business or the failure to have someone oversee the trending and mitigation efforts. Use the data you receive to proactively improve your program. In the end, the efficiency and member satisfaction will typically more than pay for the staff time invested.
- Educate All Staff on 2019 Changes and OEP. It isn’t just Enrollment and Customer Service who need to know about the OEP change for 2019. All staff need to know members are not locked in and how to escalate problems. There should be an organization-wide effort in place to take quick action when issues are identified. If staff don’t know the changes for 2019 or about OEP, they won’t understand the urgency. It is something we should all have been doing anyway, but now there is true return on investment to retain members through OEP.
My dad’s membership in his plan occurred because I understood how to navigate the process and spoke with an educated Customer Service representative. Most people don’t have a person around them to help them navigate the complex systems we have in place. It is each of our jobs to smooth out the bumps and protect our members from plan-created barriers. There are many reasons to put these efforts in place. The new OEP is just one of them. It’s time we all check in to see if all of our member-facing and back-office teams know where they fit in this effort. Insurance is an amazing thing when it works and scary when it doesn’t. Let’s ensure our members are thankful they chose us!
At Gorman Health Group, we know how hard it is to keep all the balls in the air. We regularly help our health plan partners to improve efficiencies, compliance, and member-focused operations in ways that work in the real world. For more information on operational assessments or how we can support you, contact me at firstname.lastname@example.org.
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