Posted by Krithika Srivats, Senior Director, Health/Clinical Center of Excellence
Seismic changes in healthcare, including the rollout of the Affordable Care Act, the conversion from ICD-9 to ICD-10, and the rise of shared-risk arrangements, have compelled healthcare payers to overcome IT and operational challenges that are complex and demand specialized expertise.
For an increasing number of payers, this means investigating the feasibility of a business process outsourcing (BPO) partner. According to Black Book Market Research, 74 percent of payers are looking to BPO organizations for the expertise necessary to blend front office and back office processes.
How BPO Partners can Help Solve Today’s Challenges
Today, BPO organizations are bringing strategic thinking and innovation to the modern challenges facing payers, along with such critical, consumer-centric services as nurse triage, predictive analytics and robotic process automation. BPO organizations are much more focused on solving larger issues, such as network management, claims accuracy, and medical cost management, that enable payers to compete more effectively under the current (and ever-changing) market conditions.
Realizing these goals will require health plans to rethink their business workflows in the key areas of outsourcing services, automation, analytics, and IT integration.
Automation and Data Harnessing
Effective automation relies on good business process design, with multiple factors to consider, including systems use, business impact, data touchpoints, ROI of labor, and investment. And the ROI—from the front office and the back office—is significant.
For example, robotic process automation (RPA) reduces or can even totally eliminate the manual effort required for many activities or tasks. RPA doesn’t require back-office integration through APIs and seamlessly works with end-user interfaces and enterprise applications. The technology-agnostic solutions work well with data-intensive processes, across multiple domains and industry verticals. It offers various functionalities including:
- Responding to external stimuli and deciding when to execute functions
- Acting autonomously to use and orchestrate any application
- Bringing inherent data protections, transactional integrity across systems
- Providing clear audit trails and other system management functions
RPA delivers on two critical fronts for business success: driving significant cost savings and optimizing the customer experience. Organizations that employ automation capabilities have typically experienced significant benefits, including better agent productivity, decreased training timeline, increased process compliance, enhanced efficiency and customer experience, and higher CSAT scores through faster resolution of the cases.
Today’s analytics have moved from being descriptive and report-based to predictive and prescriptive. Predictive analytics typically involve analyzing vast sets of historical data to come up with a model to assess the likelihood of an event occurring. Prescriptive analytics would take this further by making the optimal decision in each scenario. For instance, analyzing behavioral patterns of customer segments can help identify those customers most receptive to upsell and cross-sell offers, increasing revenue generation opportunities.
Without the resources to integrate member health data and preferences, insurers may fail to meet consumers’ rising expectations for a seamless and satisfying experience. Utilize this information to help brokers sell new offerings, additional riders and make the most out of cross-selling opportunities. Increase touchpoints with members and opportunities to build loyalty—from enrollment, onboarding and health plan education to appointment reminders and change-of-life events. Aggregate member data to evaluate and re-evaluate the customer lifecycle.
Consumer Experience Services
BPO partners can help payers revamp and improve their customer care services quickly so they can meet and exceed members’ consumer-based expectations without disrupting service levels and incurring minimal costs impacts. Let’s focus on just one example of such a service—nurse triage.
A nurse triage service that is staffed by registered nurses and others with the proper healthcare certifications can provide evidence-based, experience-based guidance on whether a current or developing condition is an immediate cause for concern or can wait for either a call from or visit to the physician. At the same time, quickly directing patients to seek the appropriate level of care, instead of having them automatically default to the ED in times of uncertainty, helps lower payer benefit expenditures while delivering a value-added service that helps drive renewals.
Given that 80 percent of premiums are spent on managing member health, reducing that cost by driving better care decisions in the beginning will improve profitability as well as benefits to members.
Collaborating with a BPO partner can bring nurse triage services to market quickly. The technology is already in place, the staff already hired and trained, and reporting will be quickly enabled. With a minimum of behind-the-scenes work, the nurse triage service can begin answering member/patient questions and delivering an outstanding customer experience almost immediately.
Scalability. The ability to scale is another challenge facing health insurance organizations. Even if a payer has strategies in place to accommodate operational ramps, they may not be able to scale to meet growing demand, whether that is due to a lack of budget or not being able to find qualified people to fill the positions. A BPO provider can assist with overcoming these issues. BPO partners can also solve the need to ramp up on a temporary basis, such as during the open enrollment period, and then scale back down once the seasonal challenges subside.
In years past, that’s where BPO engagements would end. But today’s BPO partner does more. For example, when a request comes to add 25 people to handle a volume of work, the BPO organization will examine the process to see if that same amount of work can be accomplished by 20 people by removing steps or otherwise altering the workflow. Rather than just fulfilling requests for bodies, a BPO partner will look at where the payer’s current operations are and what it wants to accomplish, and then determine the optimal way to achieve that goal.
Process Optimization. An experienced BPO partner will examine all the options to determine the best course of action. This may mean eliminating or revising a process (or parts of it) rather than simply applying technology to make an inefficient process more efficient. Understanding the goal, and then selecting the best method(s) to accomplish it, is at the root of an outstanding BPO partner relationship.
Capability Enhancement. Another overarching reason to partner with a BPO organization is to quickly acquire knowledge and/or skillsets that do not currently reside within the payer organization. Rather than expending time and resources to get internal personnel up to speed, or going through a drawn-out hiring process, a good BPO organization can bring that knowledge or those skills to an organization immediately with limited lead time.
Deciding on a BPO partner should begin with an internal assessment of the payer’s needs and where the organization wants to go. The payer must have an overarching vision, and understand what is needed (at a macro level) to get there. The vision of the BPO partner must be aligned with the payer’s vision and offer solutions that will help to enhance their strategies.