Open Enrollment: It’s So Much More Than Eligibility

When we talk about open enrollment for January 1st activity, we tend to focus on the member-related situations that come during this time of new enrollments, disenrollments and benefit changes.   New benefit coverage requests will pour in and existing coverages will be modified, taxing your people and systems.  

However, often we find that the most visible problems payers contend with — in this case, a spike in new members, modified coverages, high call volume — should not consume management’s attention.  It is the invisible issues lurking in your technology, in your system integrations with partners, in your millions of lines of code, in your processes and diagnosis codes. These must be identified and scrutinized to ensure a myriad of critical member and even provider-related problems do not occur when the volume of work spikes.

Obviously, many things are already happening behind the scenes to prepare for commercial and government insurance open enrollment and the 1/1 “live” date. However, in the payer community, we find that the issues that should have been addressed were not addressed or they were merely glazed over, particularly with, system/information technology preparation. Unfortunately, these oversights can turn open enrollment into a big headache for payers, members, and providers.

But holistically addressing all potential risk areas can eliminate common problems such degradation of customer service for members, claims processing hang-ups with providers, and so on. We’ve seen all the nightmares that can happen, many of which stemmed from unaddressed technology issues with headlines splashed on major newspapers and across social media. We’ve seen the government fines and the public outcry, especially during the PPACA rollouts. These payers were not prepared and because of that lack of preparation, their products were implemented poorly. Ultimately, we need to prepare to guarantee a non-event during open enrollment and 1/1 live by rigorously scrutinizing, monitoring, and testing all of our internal systems, as well as our external system integrations with partners/vendors.

As long as our systems are finely tuned machines, issues will not arise with service-levels and customer satisfaction so headlines will not be written about you., Broadly, we are concerned with three factors:  

  1. System Management: its stability/reliability, adaptability, and performance;
  2. Data Reporting: all critical streams of data are being accurately collected, analyzed, and reported;
  3. Data Flow: data is flowing seamlessly (uninterrupted, error free input/output).

You must examine all aspects of these broad factors, scrutinizing and testing the most conspicuous and minutest. If testing reveals problems, you must understand the impacts and what you should to do to rectify them immediately so that calamity does not ensue. From what we have seen, the first and second items — system management and reporting — rarely pose problems. Healthcare companies’ IT staff know their systems so  they can figure out most puzzles and easily piece together integrations among disparate internal systems.

It’s the third item, data flow, which creates complications, particularly when you are exchanging data with partners/vendors. For example, are you confident your systems are seamlessly exchanging critical data? Is the data flow among your partners secure and error free? Everyone in your circle needs to be able to answer yes, often well before volume ticks up and new codes and rules from numerous stakeholders come down the pipe. Nevertheless, we have seen payers repeatedly falter here. System integrations are challenging, especially when your partner’s IT resources, expertise, and investment are limited.

Preparation and Solution

Our systems have huge pipes of data from numerous sources whose systems may not be as finely tuned as your system. You get data from multiple government sources and you send globs of data to them to meet regulatory and a myriad of other obligations — reporting claims, care, reimbursements. You also exchange data with your partners such as pharmacy managers and vision/dental providers. Both your systems and their systems must be updated with the latest diagnosis, treatment, and other codes. Otherwise, you will be speaking two different languages. If a data exchange problem exists, it can worsen over time and create numerous errors that accrete. Left unattended, service issues will ensue.

However, while you may have tested your systems to make sure they are up to speed and updated with the latest codes and rules, there are no guarantees your partners and vendors have scrutinized their systems as you have. They may not be constantly monitoring their systems to make sure all relevant data is being seamlessly exchanged, especially error free. The key point is that you need to be proactive and cure errors between your system and their system. Furthermore, we do not want to be curing errors midstream during open enrollment and pre- 1/1. Preparation, testing, and constant systems monitoring are key — the flow of your data to your vendors/partners and the flow of their data into your system.

To help you mitigate open enrollment and 1/1 live technology issues, internally and externally with your partners, we created the following checklist. But remember even if you have made the following changes, all of your systems and integrations with partners should still be subjected to rigorous testing and monitoring.

The Checklist

  • Ensure all rules governing individual, group, and government policies have been implemented. This includes standard claims processing rules, member liabilities, government-mandated health and prescription drug coverages, as well as member benefit and provider reimbursement modifications. 
  • Ensure the implementation of treatment codes/processes for new treatments/technologies.
  • Ensure that special handling and authorizations are correctly configured.  For example, do special handling rules and reimbursement guidelines need to be implemented to automatically isolate payment of the claim and trigger payment authorization when requirements have been met?
  • Validate error free integrations (data flow in/out) with federal/state systems, CMS (Medicare/Medicaid)
  • Valid full compliance with federal and state regulatory reporting requirements, e.g., claims data, patient history, et cetera, particularly state-specific Medicaid regulations. As benefits change and new regulations are introduced, all of that has a trickle-down effect. Every time we have changes, we need to look at that downstream data and reporting: what are we telling CMS and the state about the activities of member? What do I need to report to the government to prove that I am covering mandated benefits?
  • Ensure that annual and periodic coding updates have occured (CPT, HCPC, ICD10, DRG): new codes and terminated codes. Particularly, you need to make sure your partners/vendors are on the same page. This may require rigorous testing and systems monitoring, especially if you do not have confidence in their ability to keep their systems updated. All systems — hospitals, doctors, and other providers — should be working in concert.
  • Apply annual fee schedule updates, including Medicare and Medicaid fee schedules
  • Ensure holistic pre-open enrollment and post 1/1 go-live readiness: multiple systems need to be reviewed, updated, and potentially integrated: enrollment systems, claim processing systems, medical management systems, data warehouses.

Of course, no list is comprehensive. There are a number of other technology issues that may need to be addressed. Depending on your partner relationship and individual resources, you may be able to solve them in-house or you may need to turn to a consultant. We have helped numerous payers overcome these and other challenges. Ultimately, we need to make sure open enrollment and 1/1 is a non-event. Otherwise, it’s headaches and headlines.