Publication: Employee Benefit Adviser
Publish Date: August 2015
By Craig Kasten
AUTHOR: CRAIG KASTEN, CEO and Managing Partner
The Affordable Care Act (ACA) has introduced many changes to the health benefits landscape – starting with making an additional 30 million Americans eligible for health benefits. As enrollment expands, it will place significant pressure on outdated, manual health benefits administration processes. Health payers that cannot service members with the speed and accuracy those members expect will have difficulty retaining them.
Expanding access to care at an affordable cost requires new technologies and approaches. Health payers need to look at where they can introduce automation and which areas absolutely require human intervention.
Specific innovations in benefits administration software are paving the way and supplying the technological framework to a future primarily based in cyberspace rather than buildings filled with people. Examples include:
- Deployment of robust web portals to meet member and provider expectations. Through their interactions with retailers and other industries, consumers have become conditioned to using web-based, self-service portals. Benefits administrators and payers must make this same self-service available to their members and providers. By providing most answers through online portals, payers can focus call center personnel on providing higher value services to members and payers while reducing their costs.
- 24/7 online claims administration. Most benefits administrators and health plans cannot afford the high overhead around-the-clock staffing requires. By implementing online claims administration technology, benefits administrators and health plans can offer 24/7 processing of incoming claims and authorizations, removing delays and delivering resolution faster.
- Automated claims administration process. New innovations are replacing manual tasks with automated, rules-based technologies that will quickly and accurately process 100 percent of all claims edits, and provide immediate authorization for certain agreed-upon services. Additionally, recently-introduced technology is enabling providers to process a prospective benefit claim to determine reimbursement levels and patient responsibility in real time. These technologies are helping organizations prepare for the future by enabling the administration of the new bundled payment formulas that are essential to containing spiraling healthcare costs while turning the often-contentious relationship between providers and payers into a partnership.
- Paperless claims administration. New imaging technology and database designs are eliminating the need for massive farms of file cabinets (and the real estate required to house them), replacing them with electronic files that can be securely stored in a fraction of the space, either on-premise or in the cloud. Electronic files make the data easier to search for and access while providing protection against disasters such as fire and flood.
- Operational transparency through performance dashboards. Filterable, online access to real-time dashboards monitors key performance indicators to deliver greater visibility into financial operations. Driven by powerful performance data analysis engines, these dashboards offer complete operational transparency, helping benefits administrators and health plans improve business efficiency, solve problems and streamline the delivery of benefits. Retrospective data analytics are even providing unprecedented clarity regarding the true cost of pharmacy benefits management, finally giving large employer groups and other plan sponsors a means to bring the skyrocketing cost of prescription medications under control. The ability to obtain multiple supplemental benefits, such as dental and vision, from a single source and administer them using a single technology platform creates further efficiencies.
This vision is very different from the way most payers operate today. But it is essential to thriving in the future.