When future historians look back on the health insurance industry, it is likely that a line of demarcation between the “old ways” and their present will be the passage of the Affordable Care Act (ACA).
It not only expanded healthcare coverage access to millions of Americans, it created a marketplace where payers had (and have) to work directly with millions of individual insurance neophytes rather than a smaller number of benefits professionals.
The downside of all this change is that many health payers are poorly prepared for it. Strategies and processes that worked well pre-ACA do not always translate well post-ACA. In order to succeed, payers need to adopt new strategies and new ways of thinking.
Here are some of the biggest changes that are proving problematic for payers.
1. Processing adults and children differently.
Among the Essential Health Benefits provisions in the ACA are the requirements that payers must offer pediatric vision and dental benefits to participate in federal and state exchanges.
While it makes sense on a human level, it can wreak havoc with payer systems because for the first time in history, adults and their dependent children on the same policy have different benefits. Yet deductibles and other out-of-pocket expenses from all family members must roll up into an overall total.
Legacy systems were built with the assumption that all benefits would be the same. Payers must now add the ability to track these differing benefits accurately, either by revising their systems, purchasing new technologies, or partnering with benefit management organizations that already have these capabilities. However they go about it, the new solution must still be able to integrate easily with those legacy systems in order to be effective.
2. Replacing manual claim handling with automated systems.
Just attempting to review every claim manually, especially those that include government subsidies, will quickly overwhelm even the best-staffed payer organizations. Add in all the other paperwork generated by members and providers and it becomes impossible to keep up with the workload.
Automating these processes allows payers to reduce manual work so they are only reviewing the exceptions, helping them manage the increased volume while ensuring faster resolutions for all. It also helps keep costs from rising along with membership; a good automated system can handle 1 million claims as easily as 100,000.