Of all the changes brought on by the Affordable Care Act (ACA), one of the most profound was its effect on the business operations of health payers. What was once primarily a business-to-business (B2B) transaction between payers and employers suddenly became a business-to-consumer sale. Roughly 13 million of them, in fact.
To say that most payers were ill-equipped for the sweeping changes it brought is an understatement. Almost overnight, payers had to learn how to:
• Attract and retain millions of individuals who already have expectations for digital and retail-like customer experiences
• Integrate front office and back office processes to enhance the customer experience and eliminate process gaps along with clerical errors
• Gain the ability to continuously evaluate the customer lifecycle and the likelihood that members are in need of and will purchase and enroll in additional services
Eight years and hundreds of millions of dollars later, many payers are still struggling. What many have discovered is they can't make this transformation alone. They need to work with the new breed of Business Process Outsourcing (BPO) organizations.
From tactical to strategic
Black Book Market Research says 74 percent of payers are looking to BPO organizations for the necessary expertise to blend front office and back office processes. Yet they are looking for more than the "lift-and-shift" (transferring work such as application development, claims processing, and authorization management to lower-cost geographies) that BPO organizations offered in the past.
Today, payers are asking BPO organizations for help with strategic thinking and innovation around the modern challenges they are facing. They are also turning to BPO organizations for critical, consumer-centric services such as nurse triage, predictive analytics, and robotic process automation.
The most popular BPO approach today is one of "transform-and-shift." It includes:
• Helping payers find ways to improve programs rather than just trying to lower transactional costs
• Looking at the business goals and needs of payers, and then developing solutions to meet them. In some cases lift-and-shift may be employed; but in others it may be eliminating a process entirely or automating all or part of it
• Taking a more consultative approach to getting the job done that considers all the new tools and technology available with a mindset to take an entire end-to-end process-driven approach with emerging metrics rather than applying a piece-by-piece functional outsource placement approach.
Payers are dedicating more resources, technology, and money to network management, claims accuracy, and medical cost management in order to lower costs, improve provider and member satisfaction, and make healthcare more accessible. Realizing these goals will require health plans to rethink their business workflows in the key areas of outsourcing services, automation, analytics, and IT integration.
Finding the proper shore
Today, rather than simply lifting services from the United States and relocating them to India, Asia or another far-flung geography, organizations have a great deal more choice. The criticality of choice is especially acute in healthcare.
The new BPO has evolved to address the unique environment and needs of healthcare organizations and bring the appropriate solutions and services to meet their goals. As a result, outsourcing is no longer synonymous with off-shoring. It could also mean near-shoring to a closer geography that shares cultural and language similarities with the U.S., such as Canada or the Caribbean, or even right-shoring within the U.S. due to regulatory or other requirements, or even member expectations.
It's all about assessing a client's opportunities and challenges, and customizing a solution that makes them more competitive in the marketplace. And as outsourcing becomes more accepted and mainstream, it will be viewed as just another link in a global, integrated supply chain.
Improving the consumer experience
One of the most critical areas where BPO can contribute is in helping payers improve the consumer (member) experience.
Prior to the ACA, customer care primarily consisted of answering phone calls or emails around basic questions during normal business hours. Today, after years of being provide exceptional experience within other industries, members expect far more, such as 24x7x365 availability.
They also want the ability to obtain answers however they prefer – by phone, email, text, online chat, self-service web portal – or a seamless combination of these methods. They also expect to be able to use the device they prefer.
BPO partners can help payers revamp and improve the customer care services quickly, so they can meet and exceed members' consumer-based expectations without disrupting services levels and while incurring minimal cost impacts.
Other areas where the new breed of BPO organizations can help payers meet the rising tide of consumerization include:
• Scalability – Even if payers have strategies to accommodate operational ramps, such as during the ACA's open enrollment period, they may not be able to scale to meet growing demand. A BPO partner can assist with ramping up needs on either a temporary or permanent basis.
• Process optimization – An experienced BPO partner will examine all the options to determine the best course of action. This may mean eliminating or revising a process (or parts of it) rather than simply applying technology to make an inefficient process somewhat more efficient. It's about the ability to ensure that the payer doesn't just get "better," but that it does so in a way that meets member expectations.
• Capability enhancement – A good BPO organization can bring new knowledge of skills to an organization immediately, with limited lead time, helping payers meet current and long-term goals in a way that improves operations and customer satisfaction.
Payers have traditionally preferred to keep as much of the business operations in-house as possible. But in a rapidly changing, consumer-driven world, that simply may not be an option in every situation.
Today, BPO partners are taking an active role in helping payers manage change, internally and externally, to put themselves in a better position to take advantage of the opportunities healthcare reform has brought. By selecting the right partner, payers can position themselves to gain a competitive advantage in the present while setting themselves up for an even brighter future.
Anand Natampalli is vice president, global business development, for HGS, a provider of end-to-end business process services for numerous Fortune 100 health insurance companies and large provider organizations.
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