When open enrollment 2016 closed for the Health Insurance Marketplace, U.S. consumers made nearly 13 million plan selections in which they were either first-time enrollees or they adjusted their plans. Add Medicare and commercial plans to the mix and open enrollment 2017 will mean another expansion of healthcare coverage nationally, as well as a deluge of claims to process.
For health plans, open enrollment can be a blessing and a curse: the blessing of increased enrollment; a curse if your people and systems are not ready to handle the volume of enrollments and new or changed policies. In addition, often preceding open enrollment comes a number of new or substantially revised federal and state guidelines. And on the provider front, we see changes in how care is given and reimbursed, especially for new types of care. You’re always reacting to these new realities — constantly adapting so your people and systems understand these new contexts.
Moreover, with the floodgates officially opening on November 1 for Marketplace (October 15 for Medicare), regulators, providers, insurers, brokers, large/small businesses, and medical professionals will, unfortunately, not be working in concert as much as we would like. We all have the requirements, but we may interpret and implement them differently as we prepare for the flood.
Open enrollment can grind even the best systems to a halt, or cause immense delays and other complications if your operation is not prepared to handle the volume and sheer number of different behaviors from all of those players. In addition, even internally, your product benefits might have changed, posing new complications for your systems and people.
While open enrollment deals with the member side of the equation, there are annual changes occurring on the provider side, as well, that must be implemented for the upcoming year. Contract updates, new payment models, procedure/diagnose code updates, and regulatory reporting requirements will need to be implemented. Providers may have also made other internal changes to keep pace with the volume of new patients. Your people and systems will be on the receiving end of those changes. You absolutely need to account for these new behaviors — and have systems that are capable of understanding it. System nimbleness is key.
Avoiding the Monkey Wrench
With so many factors, so many players, combined with a huge uptick in volume, you must ensure you have made all the right moves: that your technology and labor is ready for the best and worst possible outcomes. As you batten down the hatches in preparation for the storm of open enrollment, it’s a good idea to check for gaps in your people, processes, and technology to keep the ship afloat and on course.
During the ebb period before the volume spike, you need to scrutinize your operation from top to bottom, from the high-level details to the most minute. You need to believe in the possibility your people and information technology can fail in order to root out weaknesses. You might think you have built a flawless machine, but even the tiniest crack — one error hidden in a swamp of code — can be broken wide open.
Taking Action: Planning, Preparation, Solving
A basic, top-level analysis of your operation should begin with resource demand planning, e.g., “I predict based on the best available data there will be X number of new enrollments which means I will need at least Y number of resources (labor and technology) to manage all the paperwork, data, and tickets.” That may also include an assessment of whether your reps have reliable software at their fingertips to handle the uptick in customer service calls.
This resource demand planning must be done across the enterprise to ensure all your people, processes, and technology are prepared for the influx and volume of change. However, while resource demand planning is important, it’s an incomplete assessment. We must drill deep to ferret out fatal flaws. The burden of open enrollment volume will be mostly handled by your information technology. Your claims system will need to be airtight. It will also need to rapidly evolve with the whims and needs of all the players I described above. Also, your care management system must have capacity for exponentially more cases, as well as all the provider-consumer-government dimensions that come with ensuring the consumer is getting the treatment they need.
Thorough quantitative and qualitative assessments must be done. To help with those assessments and find solutions to problems that arise, we’ve developed resource estimation calculators, e.g., “I need to build a complex provider contract, so I need to understand how many hours it is going to take if I also have to modify 100 contracts for this change.” At HighPoint, we look at the change that needs to be made, consider the time it takes to do each function, then determine how many people it will take to get the job done based on available tech resources. We’ve done these calculations — and more complex assessments — for a number of clients: tailored to their individual resources, systems, and needs.
You should also assess whether your operation is capable of quickly processing complex commercial policies pieced together by brokers, which can gum up your resources while the open enrollment deluge is underway. If you receive X number of paper-based requests, modifications, and so on — all of which contain special rules pertaining to these unique policies — exactly how much labor will you need? Can your systems be made more efficient to reduce labor costs? Are you also accounting for provider-hospital exceptions, which create additional special processing rules?
Open enrollment, along with the implementation of all the standard annual updates, is our sweet spot. We know the systems health plans and health benefit administrators are working with. We have the resources to identify and remedy weaknesses. Over the years, we’ve developed a tried-and-true methodology that begins with taking that objective look at your operation, the entirety of your resources and capabilities, from end-to-end. This discovery phase tells us what needs to be done so we can immediately begin to eliminate issues, especially fatal flaws. Multiple layers of testing are involved to ensure your system is ready. We’ll also simulate conditions, including open enrollment scenarios, and monitor modified systems.
Pre-open enrollment systems analysis will eliminate issues that can cripple your operation. It takes time to be methodical, but it’s worth it to look under the hood and decide whether you have the tools, people, and capabilities in place for open enrollment — not to mention your everyday run-of-the-mill priorities and concerns. Preparation is key; so is testing and objectively scrutinizing whether you can take on highly unpredictable volume. Knowing your hatches are secure and you have prepared for the worst is a plus too.