Solve 4 Challenges in the Enrollment and Billing Lifecycle to Improve Member Experience

Matthew Swendsen, Principal Solution Marketer, Oracle Financial Services

Enrollment and billing processes and workflow

Healthcare payers face challenges at every turn in the enrollment and billing lifecycle. For example, a large corporation is evaluating its employee health insurance plan. It’s looking for a highly specialized health plan and would like to roll it out in the next open enrollment period. They discover, however, that their preferred health insurer cannot configure, price, and quote the specified plan options in time to meet the open enrollment deadline. As a result, the payer did not get the deal. This same insurer struggles to adapt products as regulatory requirements change, elevating risk. The inability to nimbly configure, price, and quote also constrain its ability to expand into new geographic markets.

Another health insurer faces chronic delays in the underwriting phase. The insurer is caught up in paper-based processes, data that must be rekeyed from different systems, and email-based approval chains and workflows. These disconnected processes require significant manual intervention that elevates costs and negatively impacts customer relationships at the earliest stages. The insurer faces similar hurdles in the enrollment submission, activation, and fulfillment phases as it, once again, requires data from many different sources and channels, and relies on manual processes to collect and validate missing data. As a result, it’s consistently late in issuing enrollment cards, which triggers financial penalties as well as member complaints.

The challenges don’t end when cards are issued; they continue throughout the billing and collections process. For example, a large insurer finds that many of its tier-one clients are beginning to request a consolidated bill for all the products it purchased. The insurer is struggling to meet this request as it has multiple billing systems across its various lines of business. In addition, as it continues to grow, it’s challenged to efficiently manage the creation of customer structures, including billing hierarchies, and to achieve real-time insight into billing status. Finally, it offers limited self-service capabilities for members, so they are forced to email or phone the company’s customer service center for the simplest of inquiries. This approach drives up costs, slows service responsiveness, and builds customer frustration.

4 challenges in the enrollment and billing lifecycle

Below, we describe a few examples of the challenges and improvement opportunities at each stage of the lifecycle. Several root causes underlie these challenges, limiting payers’ ability to boost profit, improve the customer experience, and reduce risk:

  1. Fractured data flows—Payers struggle with duplicative data stores and inefficient integration across the entire enrollment and billing lifecycle. Rigid legacy applications and incompatible technologies prevent seamless data exchange and a single view of the customer across all lines of business. This translates to missed opportunities to create exceptional value early in the customer acquisition process and throughout the relationship.
  2. Inefficient processes—Disjointed point systems, which lack API compatibility, and legacy manual processes lead to inefficiency that drives up costs and makes it difficult to rapidly launch new products, offer flexible billing, and bill for all contracted charges. E-mail-dependent workflows and approvals delay processes across the lifecycle, including launching new offerings, calculating pricing, providing customer information updates, and delivering a seamless billing experience
  3. Slow systems and limited scale—Most legacy systems, which require hardcoding and extensive IT team intervention for even the simplest updates, cannot pivot rapidly to meet changing business needs. Further many continue to rely on batch processing that does not deliver the real-time information and decisions that the market demands. And, many organizations struggle to scale their infrastructures, which complicates their ability to add lines of business, expand geographically, and grow through acquisition.
  4. Security and privacy complexity—Security threats and requirements continue to escalate. Legacy infrastructures typically contain multiple data stores that fuel dozens of point solutions and often lack adequate preventative controls and audit trails. This reality complicates compliance with internal controls as well as regulatory requirements and elevates overall risk.

Essential capabilities to solve these 4 challenges

Six core administration capabilities are essential to empowering payers to overcome these persistent challenges, unlock new opportunities, and build stronger relationships. They include:

  1. A central golden member record and automate end-to-end processes
  2. A microservices architecture that enables progressive transformation, flexibility, and performance
  3. Rules-based and highly configurable applications
  4. API-rich approach to enable real-time processing and data access
  5. Multiple consumption models—functional components, end-to-end solution, calculation engine
  6. Security with preventable controls and extensive audit trails

How Oracle can help

Oracle Health Insurance core administration, is a leading SaaS solution that includes policy administration, revenue management, and billing for healthcare payers. It is purpose-built to help healthcare payers compete agilely in a constantly changing landscape, delivering the essential capabilities previously identified and much more. Our solution drives frictionless onboarding and enrollment, creates a central golden member record, enables efficient member management, and ensures accurate, efficient, and flexible billing. And it also supports both commercial and government health insurance and billing from a single platform.

Modernization is imperative, and today, with Oracle’s componentized approach, you can chart your course while taking advantage of all that our industry-leading cloud-based solutions. Designed for simplification, our enrollment, and billing solution ensure a better member experience.