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How health plans can enhance the customer experience with the right foundation for managing benefit changes 

In today’s digital age, consumers are more empowered than ever before, driving payers to re-design their operating models to place the customer at the center. This shift of control from payers to consumers is influencing how healthcare companies are organized and structured, and has implications all the way from operating model to designing plan benefit offerings. In this Customer 4.0 world, seamless and agile service delivery is key to meeting the increased demand for flexibility and choice in benefits plans. However, many payers lack the organizational capability to take advantage of this flexibility and quickly change and configure their benefit offerings to meet consumer, market and regulatory changes.

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Health plans face three key operating model challenges—people, process, and technology—all of which can be addressed by a well-supported benefits governance structure. 

Challenge #1: Teams are siloed

It is important to consider how the benefits, product, clinical and regulatory groups work together in establishing an agile organization. Keep in mind that regulatory and go-to-market deadlines also necessitate the need for rapid decision making unhampered by different approval levels. Utilizing cross-functional workgroups expedites the benefits change review process and increases transparency among stakeholders to quickly respond to consumer needs. 

Challenge #2: Clearly stating what is included in the benefit

Organizations can struggle with clearly articulating what is included in a particular benefit. Medical policies help provide this definition, identify what is in and out of scope, and potentially include the relevant procedure and/or diagnosis codes. An overarching policy guide aids decisions so there is consistency in what a benefit is and how it is administered. It can also provide guidance on how to communicate to both members and providers. 

Challenge #3: Understanding clinical and administrative system alignment

Benefits organizations need to ensure they establish a system of record or source of truth. Commonly, the majority of benefits configurations commonly exists in two or three systems: the Benefits Management System, the Core Administration (Claims Processing) System and the Care Management system. Understanding the benefit information that lives in each of these system configurations as well as the process and sequence for updating them is critical to ensuring all systems have up-to-date information including accurate tracking of visit accumulators, deductibles and co-insurance. Well run benefits functions are supported by processes that add member value and clarify internal roles and responsibilities. 

Creating alignment and governance 

A benefits management organization designed to enable delivery of consumer driven benefits is underpinned by strong governance and integration of technology. Creating alignment begins with mapping out your organization’s benefit configuration process, starting with the question of what and how systems can be updated each time a benefit changes. It is critical that the benefits management organization is closely aligned with an organizational unit such as Marketing that has a strong command on the pulse of the consumer. Payers can build upon their operational strength to gain a competitive advantage in being able to shorten go-to-market cycles and enable their product offerings to quickly respond to employer and consumer benefit needs.

To succeed in this fast changing world, organizations must design their operation model and benefits offering with the customer at the center.

Contact the authors

  • Marian Lee

    Marian Lee

    PA healthcare expert

    Marian is a business design expert who specializes in business transformation and operational excellence in healthcare

    Insights by Marian Lee
  • Emily Korber

    Emily Korber

    PA healthcare expert

    Emily uses her expertise in business design and sourcing to enable transformation and technology innovation for healthcare clients

    Insights by Emily Korber

Contact the healthcare team

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