Paul Maaskant, Director, Product Management OHI Components, Oracle Financial Services | June 6, 2023
First impressions can set the stage for successful business relationships. For healthcare payers, those impressions are often made during enrollment. While member enrollment may appear straightforward, payers face considerable challenges in managing the process and vast amounts of data that accompany it, especially in the growing individual health insurance market. These challenges set the stage for higher costs and a diminished sense of member satisfaction.
According to the Centers for Medicare and Medicaid Services (CMS), the individual health insurance market saw a 13% increase in enrollment via exchanges last year, with 3 million new entrants. The Affordable Care Act (ACA) marketplaces have enrolled nearly 16 million people, indicating the growing participation in individual health insurance markets.
As participation in individual markets continues to rise, it's increasingly evident that managing member enrollment data is far more complex in practice than it may seem in theory. This is because nearly all healthcare payers face 5 challenges when it comes to effectively managing critical data:
The biggest challenge payers face is heterogeneous enrollment data influx. Although there are existing standards for the exchange of member enrollment information, such as the X12 834 in the United States, many of these standards are relatively flexible in their implementation, which creates complexity and confusion. For example, trading partners, group customers, and exchanges all follow a slightly different implementation of the X12 834 standard, leaving the payer—the receiver—to sort out the differences. On top of that, many group customers do not even adhere to a standard, instead sending custom comma-separated value (CSV) files with member information. As a result, the payer has to create and maintain hundreds if not thousands of mappings—increasing costs and complexity.
Another challenge involves the various channels through which enrollment updates arrive. Conflicting updates from different channels create problems, and legacy systems have no good way to deal with data conflicts. Payers have extended their architectures to enable the receipt of enrollment information through multiple channels causing redundancy in several applications and increasing IT complexity.
File-based enrollment updates are still prevalent in the United States, but the enrollment information in a file is nearly always a snapshot of the most recent information regarding the member and the member’s enrollment. It does not reliably specify what changed, so it’s up to the payer to identify the changes, such as a new address, indicating the member has moved. Detecting these changes is critical because they trigger business processes, such as corrective billing and the generation of member letters. Managing this process, however, is a time-consuming and expensive process with legacy systems.
Payers receive most enrollment updates via files containing thousands of members' updates. Legacy systems typically treat such files as a single unit of work, which means it is not possible to process only a subset of the updates. This is problematic because often a file contains issues for only a handful of members, but that handful of issues prevents all other updates from being loaded. This leads to process inefficiency and slower enrollment times.
Lastly, given all the challenges already mentioned, payers tend to keep creating custom surround code, fixing specific issues at the expense of increased complexity and maintenance costs. This makes it very difficult for payers to elevate their architecture to higher levels of interoperability, potentially missing out on opportunities to leverage new technologies, such as machine learning and artificial intelligence.
To address these challenges, a modern enrollment solution requires advanced capabilities, such as the ability to deal with different electronic data interchange (EDI) formats efficiently and effectively, a single transparent pre-enrollment process to validate and enrich the influx of enrollment data, and the ability to version and automatically roll back updates that are rejected.
Oracle Health Insurance Data Exchange Cloud Service and Oracle Health Insurance Policy Administration Cloud Service offer solutions that enable payers to simplify healthcare IT, achieve greater levels of operational efficiency, reduce costs, and be prepared for the future of healthcare insurance. These cloud-based solutions provide configurable EDI intake, sophisticated mapping functionality, a single business process for all enrollment data influx, and native enrollment versioning and comparison capabilities. They are also fully interoperable through extensive APIs, allowing payers to leverage new technologies such as machine learning and artificial intelligence.
Healthcare payers process massive amounts of data daily, and with the adoption of advanced analytics and modern enrollment solutions, they can improve enrollment speed, reduces costs, and create a more frictionless experience that boosts customer satisfaction, as well as set the stage for streamlined claims processing.
To explore how you can improve your enrollment journey today, please visit our Oracle Health Insurance solution page.