An East Coast health plan experienced one of the worst critical system failures and service issues imaginable. It struggled with getting members on individual health insurance products. The issues deteriorated quickly as hundreds of members were placed onto incorrect plans, others waited on-hold for hours hoping to speak with a customer service rep to address their questions, some members received excessive premium overcharges, others weren’t able to pay their premiums, and some couldn’t confirm they even had coverage.
All fingers pointed the blame on a new core administrative and billing system. But before things could improve, they got much worse. Complaints were filed. Several investigations were launched, and executives stepped down.
What brought the health plan’s system to a screeching halt? Our analysis discovered that the health plan was struggling with adapting large amounts of configurations — plagued with errors — in its production system.
As the issues surfaced and magnified, there was a cascading affect as the configuration errors and system inconsistencies affected downstream processes. As the health plan tried to stabilize and remediate the system, further migrations were delayed. The health plan continued to struggle with system stability issues and its vendor was unresponsive and unprepared to support the configuration on the platform and help resolve the chaos that ensued.
Many claims were pending in the system. A typical first pass rate on electronic claim submissions can average around 90%, but the health plan experienced around a 50% first pass rate because of the problems it was experiencing.
Frustrated by the experience, the health plan asked IQVIA’s Healthcare Center of Excellence to perform an assessment and develop a roadmap to address the issues.
What we learned
The Healthcare Center of Excellence (COE) resources shadowed the health plan staff to see the current system configurations, first-hand, and identify the issues as they occurred. Many issues were identified as simple configuration changes to resolve data inconsistencies and resolve incomplete configurations. Based on data samples and claim extract reports, claim errors and their root cause were extrapolated and documented. That information formed the basis for our assessment findings and recommendations.
During discovery meetings, we learned how we could best help the health plan position itself for success in meeting its objectives, including:
- Reducing open enrollment operational issues.
- Improving operational service levels to ensure a better customer experience.
- Instituting governance practices focused on quality that coordinate with future migrations.
- Empowering the health plan to directly maintain the system and reduce its dependency on the system vendor.
- Reducing the number of claims pending on first pass, which will improve provider and member satisfaction.
- Improving the government’s confidence in the health plan’s operational and service capabilities.
also identified risks during the discovery process, including:
- The configuration team had no knowledge of system changes occurring upstream.
- Configuration changes were completed based on outdated or incorrect information, as there was no repository for the business and technical requirements. For example, tables and spreadsheets had no version control.
- There was a lack of confidence that the non-production User Acceptance Testing (UAT) environment was representing the expected behavior in the production environment.
From our assessment, we identified gaps occurring in configuration coordination. The Healthcare Center of Excellence identified six processes that needed attention in order to implement the platform’s required infrastructure.
- Change control management processes
- Building a central business requirements repository
- Global and detailed configuration design documentation
- System environment management
- Quality assurance
While these topics are much broader than the configuration issues, we felt it was important to identify and address the processes and system management activities that were putting the ongoing configuration’s quality at risk, therefore contributing to the problems and downstream impacts.
Based on our assessment and recommended roadmap, the health plan established a dedicated unit to bring the configuration in-house and move away from sole reliance on the vendor to support the configuration.
With the configuration components owned and supported by disparate operational areas, we recommended a formal configuration change management control process. Having this kind of centralized traceability into what, when, and why something was changed would increase the speed and quality of future configurations.
Having a formal configuration change control process gave the health plan a structured process to monitor requests from the onset through deployment, ensuring all artifacts are gathered, all notifications are made to dependent teams, and sufficient testing has occurred.
Improved management tools
The health plan used a number of different issue management tools, but lacked the full support for change management processes. For example, a separate Excel spreadsheet tracked the issues logged in multiple systems.
Along with instituting formal configuration change control processes, we recommended standing-up a new configuration change control board. This permanent, cross-functional team, now approves all changes. The board’s responsibilities include ensuring all requirements are appropriately gathered, system impacts identified, solutions developed, and all testing is successful and tracked back to a specific requirement.
Through our roadmap, the health plan achieved system stabilization — something it needed desperately — to improve its processes along with both public and government perception and confidence in the plan.
The Healthcare COE quickly recognized the underlying issues and not only came up with a plan for remediation but helped the health plan implement that plan successfully. Today, the health plan is enjoying operational success with a high auto adjudication rate and high customer satisfaction.
To learn more about the HighPoint Payer Technology and Operations practice, please reach out to Steve Schneiderman, vice president, payer technology and operations.