Payers face a constantly changing environment fueled by consumers who demand high-quality care, an uncertain regulatory landscape, and competition from upstart, tech-first plans looking to corner segments of the market.
Health plans, Pharmacy Benefit Managers (PBMs), dental & vision plans, Accountable Care Organizations (ACOs), and First Tier, Downstream, and Related Entities (FDRs) want to do more than stay ahead of the curve. To do that, you need a partner than can help you anticipate, adapt and respond to changes and focus efforts and resources on risks and opportunities that can drive better business performance.
Members have more options than ever when selecting a health plan and they expect best-in-class experiences at every turn. Unlike other stakeholders in the healthcare ecosystem, payers have limited interactions with their customers, so they need to make all experiences positive and memorable. How we can help:
Payers are delegating more functions to vendors than ever. CMS, and other regulators, have taken notice and now want to see robust oversight programs in place to ensure vendors are compliant and are providing seamless experiences for members.
Basic numbers on a spreadsheet no longer suffice for today’s payers. The metrics must be real-time, provide insight into the data behind the numbers, and leadership needs to be able to act quickly based on reporting. How we can help:
There are limitless opportunities to automate processes within a payer’s operations. Automation can reduce errors by eliminating manual controls and can improve turn-around times, resulting in happier members and lower instances of noncompliance. How we can help:
As payers grown larger and acquire other organizations, org structures, engagement and operating models, and communication channels need to be optimized for efficiency and growth. Payers need to be agile while keeping administrative costs low. To achieve this, efficiency opportunities need to be uncovered and implemented throughout the organization. How we can help:
Compliance can no longer be an after-thought. Payers must promote a culture of compliance throughout the organization so that compliance requirements are on the forefront of everyone’s thoughts, not just when a Program Audit is imminent. How we can help:
Audits can be leveraged more than ever as a strategic resource to provide guidance based on broad and deep skill sets and perspectives; analytical and digital capabilities; and internal knowledge of operations, strategic goals, and risk and control structures. How we can help:
Providers are extremely important to the healthcare ecosystem. It is important to keep providers happy as they will be interacting regularly with payer members—a member’s positive interaction with a provider can result in a positive perception of the payer. How we can help:
Provider Directory Process Improvements – CMS has been laser-focused on provider directories over the last three to four years. It has been conducting more and more provider directory audits—and not only have the audits been bad (40%-60% incorrect information within the audit samples) the results even seem to be trending downward. There will be more audits and more penalties in the coming years, so we have been partnering with plans to implement process improvements to keep the directories up-to-date and correct.
Future State Engagement Models – Recently we led an engagement at a health plan to define an engagement model between its Medicare Operations Functional Areas and Shared Services to ensure operational efficiency. Deliverables included current and future-state process flow charts to visually showcase recommendations and opportunities for improvement, RACIs, and a future state roadmap.
Member Experience Analysis – We reviewed the Member Experience processes at a regional payer to data-mine appeals and grievances data so leadership could see the causes and trends related to member dissatisfaction. Our team built dashboards and implemented feedback loops into the sub-processes, and between business units, so issues could be acted on timely and consistently.
Data Integrity for Member Mailings – We assessed the controls and processes in place for ensuring the integrity and proper processing of member data by the Analytics Department and operational business units to provide to the Mail Room for mailing to plan members. A review was performed of the operational controls and coordination of information to identify and mitigate risks for information breakdown and the distribution of erroneous member information to the mail room prior to being mailed to members.