Payers Seek Cost, Integration Efficiencies for Value-Based Care

Health insurance is no longer primarily a business-to-business transaction between payer organizations and employers. Today, payers must be prepared to holistically meet the needs of millions of individual consumers—from onboarding and first appointments to billing and wellness and retention. Cost management has always been a core focus area for health insurers, but in a value-based world, costs that previously had been absorbed by large group plans now need to be identified as medical or administrative costs in order to meet the medical loss ratio requirements outlined in the Affordable care Act. Payers are dedicating more resources, technology, and money to network management, claims accuracy, and medical cost management in order to lower costs, improve provider and member satisfaction, and make healthcare more accessible. Realizing these goals will require health plans to rethink their business workflows in the key areas of automation, business process outsourcing, and technology integration. Automating efficiencies Automation reduces or eliminates manual processes for many tasks with data-intensive processes, across multiple domains and verticals. It acts autonomously to use and run multiple applications, bringing inherent data protections and transactional integrity across systems and providing clear audit trails. For example, significant capacity optimization can be achieved by connecting and building business rules on multiple applications. This saves agents from toggling between systems, enabling them to handle increasingly complex transactions. Effective automation relies on good business process design and can have significant return on investment. According to the BPO analyst NelsonHall, automation can reduce organizational costs by up to 30 percent within three months of implementation. Business process outsourcing According to Black Book research, as many of 74 percent of payers are looking to business process management experts that have the necessary expertise to blend front office and back office processes to eliminate downstream impacts of transactions which can result in process gaps and clerical errors, so they can focus more internal efforts on managing risk and delivering an outstanding customer experience. This approach makes sense as the number of individuals seeking health plans continues to rise. The ability to manage processes efficiently will quickly become a lower-value contribution to the bottom line. In addition, BPO organizations that work across multiple verticals are able to bring the best practices from each, improving the level of quality and service overall. According to NelsonHall, a healthcare industry outsourcing analyst firm, the current global BPO market is estimated at $2.5 billion, and is expected to grow by nearly 6 percent annually through 2018. BPO success is very much about building good partnerships. Lessons learned all relate to building collaboration based on a very fine balance of open communication, feasibility, strategy, and trust. In fact, strategic partnerships are critical for companies looking to compete on a global scale, according to a recent study by the CMO Council and the Business Performance Innovation Network. The research finds that 85 percent of companies view partnerships and alliances as essential or important to their businesses. Technology integration Digital transformation has changed the paradigm by which goods and services are delivered to consumers in retail, financial services, telecommunications and entertainment, to name just a few sectors. Yet healthcare has been stymied by aging systems and a lack of health data integration, in part necessitated by patient privacy regulations. As a result, payers—although in possession of a wealth of health-related data—lack insight into members’ full history and preferences. With the aggregation of member data, insurers gain the ability to evaluate and re-evaluate the customer lifecycle and the likelihood that members are in need of and will subscribe to additional services. Without the technology to integrate member health data and preferences, insurers will fail to meet consumers’ rising expectations for a seamless and satisfying experience, leaving members frustrated and difficult to retain. Therefore, it is critical to create opportunities to engage with members and build affinity whenever a touchpoint occurs—from enrollment, onboarding and health plan education to appointment reminders and change-of-life events. Tailoring member specific service based on these unique circumstances and preferences is dependent on a robust data analytics platform within the insurer organization. Regardless of the engagement methods used, the goal is to amass integrated member data to identify individually-appropriate interventions to best manage their health. To achieve this shift, insurers will require a cloud-based platform integrated into business process outsourcing (BPO) services. The total solution must go beyond the member-facing channels to also provide integration with enterprise customer relationship management (CRM) platforms. From an operations perspective, such a platform would facilitate streamlined health plan set up, claims administration and member lifecycle management. All member participation information could be captured in a CRM that integrates with multiple back-end systems to inform and accelerate the sales process. Back office agents could leverage the data captured within the platform to provide suggestions on how to balance member costs per month with the best possible outcome; adjudicate or pay claims quickly and automatically; conduct root-cause analysis before a new plan is implemented; proactively look for claims-related savings opportunities and initiate recovery; and make the entire end-to-end process more efficient and accurate. Health insurance plans that embrace digital transformation of this magnitude stand to achieve substantial efficiency improvements in acquiring new members and providing services over the course of the customer lifecycle. Anand Natampalli, MBA, is Senior Vice President, Global Sales & Business Development, for HGS, a provider of end-to-end business process services for numerous Fortune 100 health insurance companies and large provider organizations. He can be reached at