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How Intelligent Automation Can Optimize Enrollment Season for Payors

Joel Krishnan

Senior Manager, Intelligent Automation Consulting, EPAM
Blog
  • Healthcare

The annual enrollment period is a short, yet significant, period in a health insurance company’s yearly cycle that makes a huge impact on revenue but also substantially burdens the organization’s workforce. During the 2019 enrollment season, it was projected that 159 million workers enrolled in employer-based coverage, a number that’s bound to increase in the coming years. In addition to being time-consuming and labor-intensive for payors, the enrollment process puts a severe strain on legacy systems and applications that aren’t capable of scaling in a rapidly growing market.

Let’s explore three primary challenges for payors in the enrollment process today:

  1. Short Duration Cycle: The enrollment season runs for six weeks during which billions of dollars’ worth of decisions are made over a relatively short period of time. Because these decisions have a considerable impact on the health and wellbeing of millions of Americans, payors need to be well prepared to handle this highly-intense period. Otherwise, they not only put the health of patients at risk, but their topline performance and market reputation can be seriously impacted if they don’t reduce the turnaround of enrollment cycle times.
  2. Seasonal Hires: Perhaps the most impacted part of the business for large commercial carriers is operations, including the billing and enrollment departments and call centers. These departments feel enormous pressure to reduce expenses, identify fraud and enhance customer service with constrained budgets. This results in administrative staff working long hours, requiring the addition of a huge temporary workforce (sometimes over 500 additional staff) to help share the workload. Given the time constraints, often temporary staff do not receive adequate training to perform the work.
  3. Member Satisfaction: The traditionally manual enrollment process is error-prone with a longer turnaround time to resolve issues. With customer expectations at an all-time high, members are no longer willing to wait nor tolerate errors in their benefits plan. A smooth onboarding process has become table stakes for health insurance companies.

Bottom line: the annual enrollment period must be smooth, accurate and speedy without causing too much overhead. With rising healthcare costs and increasing customer expectations, payors are looking for ways to reduce the administrative burden of benefits management while increasing enrollment and patient satisfaction.

The Current Process at a Glance

Each time an enrollment specialist processes an application and is asked to provide a quote, it requires an administrative cost. This onboarding process is expensive, time consuming and error prone. Once a contract is signed, the client database is updated, and groups are set up manually. Employers, third-party brokers and Administrative Service Only (ASO) services send the plan and enrollment information to be loaded into the system. While yearly plan changes are inevitable, often this information comes in various different formats from different channels, such as  spreadsheets, fax, emails, images, handwritten forms or scanned documents. Employees (often temporary staff) manually enter plan details into a benefit matrix, and the audit team validates this data by running claims from previous years. Once the plan information is validated, billing and enrollment specialists manually enter the information into the enrollment system.

Using Intelligent Automation in Enrollment

Digitizing the enrollment process by using intelligent automation tools can save application processing time and millions of dollars in labor costs.

Operations

Robotic process automation (RPA) bots can monitor the incoming channels and gather information to be processed. This data, in whatever form they are sent, is digitized and extracted using intelligent document processing tools, such as computer vision, natural language processing and machine learning. These tools automatically learn new form layouts and formats without the need for an IT team to configure new templates, saving time and decreasing administrative costs.

From there, the extracted data is entered into the benefits matrix or enrollment system by an RPA bot, reducing manual effort and eliminating data entry errors. A statistical data analysis model can be run to pick the right claims with various combinations to test the enrollment or plan data instead of having workers analyze and pick up claims for audit. Enrollment data is audited and validated by importing the data into a claim adjudication system and comparing it against the old and new plan to identify anomalies in the data. Once the data is successfully audited, a welcome packet is automatically sent to the employer or member by an RPA bot. The areas that were unable to be validated are sent directly to a specialist for further analysis and processing.

Call Center

The call center  is another department that’s increasingly overburdened during enrollment season. During peak enrollment season, major carriers’ call centers could receive over one million calls per month. Mostly, these calls are handled by the interactive voice response (IVR) system before routing to live agents. The 2018 contact center satisfaction index survey (CCSI) showed that IVR was able to answer only 5% of calls, while others were routed to live agents.

The first step in digitalizing this process is to modernize the IVR system to be more conversational rather than just acting as a traditional routing system. Leveraging AI technologies, such as text-to-speech and natural language understanding, the IVR system can determine more effective call intent and converse with members, reducing the percentage of calls transferred to agents. Virtual agents like chatbots that are trained to answer questions related to the plan, member benefits and policy information provide a great solution for members wanting self-service options, while simultaneously reducing operational costs. These virtual agents get smarter overtime by learning from the live agents, so they are constantly improving the accuracy of responses.

Conclusion

By leveraging technology, the process of enrollment and benefits management can be optimized and automated, ultimately reducing errors and time spent on administrative tasks to free up enrollment specialists’ time to focus on quality customer service and more high-value tasks. A technology-enabled platform also brings other significant benefits – such as higher client satisfaction, accelerated onboarding of plans and members and reduced cycle times – all while preventing millions of dollars in penalties through higher data accuracy, improved compliance, massive reduction in operating costs and increased topline performance from renewals.

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