The healthcare payer revolution. Using learning to increase human performance and drive member satisfaction.

Transcription

1 The healthcare payer revolution. Using learning to increase human performance and drive member satisfaction.

2 Effectively responding to regulatory and competitive changes in the healthcare segment requires a strategic transformation, and human performance is at the core of that transformation. The Healthcare Insurance industry is in the midst of a revolution. Regulatory changes, vertically integrated delivery models and increased member expectations have combined to create an environment in which survival requires careful planning and flawless execution without sacrificing speed to market. Effectively responding to regulatory and competitive changes in the healthcare segment requires a strategic transformation. At the core of that transformation is human performance. Those companies who emerge successfully will have created an innovative, adaptive workplace in which employees are positioned to meet continually evolving needs. Eliminating claims errors would save $17 billion annually. National Health Insurer Report Card, AMA,

3 Three main forces are driving the dynamics in the industry: INCREASED REGULATION driving accountability for efficiency in the health insurance marketplace. As an example, the Medical Loss Ratio (MLR) requirement of the Affordable Care Act stipulates that insurance providers create value for consumers by requiring the majority of customer premiums be applied directly to healthcare, not administrative costs or profit. This can create intense pressure for payers to reduce administrative costs and improve efficiency without diminishing service or member satisfaction. DIRECT CONSUMER SALES must be supported by Distribution and Sales channels. The new health insurance exchanges will provide consumers with the ability to make real time comparisons of healthcare plans and to buy their coverage independent of employer-sponsored plans. Consumers now have greater power to choose their insurance provider, making it even more important for healthcare payers to differentiate themselves and to work harder for market share and loyalty than they might have had to do in the past. HEIGHTENED SERVICE EXPECTATIONS expectations in the industry are developing, as member satisfaction rates are being used as a competitive differentiator by health insurance providers. Member satisfaction includes many facets, such as quality of care and improved access to information and support channels. To navigate this volatile environment, best-in-class healthcare payer organizations have implemented a range of strategies, including technology improvements, re-engineered business processes, and new products and services. The results include some impressive innovations across the industry. These include a new emphasis on prevention of major illness instead of simply treating those illnesses once they have manifested, and reducing hospital admissions and readmissions through the use of appropriate follow-up care. This calls for classic change enablement and health insurance providers employees are key players in enabling this new environment to succeed. Their roles involve acquiring and applying a continually evolving set of skills and knowledge in a rapidly changing environment. Ultimately, healthcare insurance payers need to provide frontline staff with critical thinking skills and the experiences necessary to effectively manage change, drive innovation, and carry out improvement initiatives. Driving Greater Accuracy and Efficiency One opportunity to drive greater accuracy and efficiency in the health insurance industry is claims processing. Healthcare insurance payers are challenged to process high volumes of claims quickly and accurately. According to the U.S. Healthcare Efficiency Index, more than 12.8 billion healthcare claims were submitted in Processing claims requires employees to work through complex steps and detailed procedures, and the results can reflect dramatic variations in employee performance. To improve this situation, many organizations have invested significant resources to implement electronic claims processing software, behavioral analytics and re-engineered processes. The goal of all such initiatives is to resolve claims correctly the first time, which in turn saves money, reduces administrative overhead, and improves member satisfaction. By monitoring and actively managing processor behaviors, the organizations can identify opportunities to improve accuracy, compliance, and productivity and ultimately identify and mitigate claims issues before they become a problem. 3

4 At the same time, these initiatives change the working environment and the skills needed to succeed in it. To succeed, claims processors need to be nimble, adaptive and agile and they must have the right learning tools in place to support them. A Proficiency Dilemma: The Claims Processor Change in the health insurance industry will continue for the foreseeable future. Yet training programs for many roles in the field are often based on an outdated model of attempting to pour any remotely relevant information into learners heads, without reinforcement or updated training when industry conditions change. Let s consider one service advocate role and the training challenges that can emerge as a person in that role adapts to a quickly changing work environment: the claims processor. A typical training program for people in this role might cover information on the following general subjects: The systems they will use to do their jobs, knowing that those systems have quarterly or annual updates that will change functionality and appearance. The organization s health plans, which will change as the organization grows by acquisition, encounters service area reductions, and launches new or altered products based on market needs and regulations. The processes for reviewing and resolving claims, knowing that business process improvements, system upgrades and external regulations will change, eliminate and add to these processes throughout the year. Standard training programs skimp on development of the skills and behaviors that claims processors need to master. Examples include: Analytical thinking and problemsolving skills. Resourcefulness to find tools, information, and updates. The ability to handle constant change Research and experience shows that practice doing the job before working with the live customer data is the best way to reinforce these skills. Of course, claims processors need system, product, and process knowledge. But the most productive way to develop that knowledge is within the context of hunting for answers and making decisions in an environment that mirrors the job, not through rote memorization of information. At core, the role of the claims processor is to handle hundreds of different if-then statements. If the member has an HMO and the claim is from a specialist, then the member is required to obtain a referral from the primary care physician before the date of service with the specialist. If the claim involves both ambulance and hospital services in a state other than the one in which the member resides and the hospital is a noncontracted provider, then the percentage of the claim paid by the member s plan is greatly reduced unless the services provided are categorized as an emergency, in which case the percentage is based upon different calculations. 4

5 The range of if-then statements that a processor may need to handle grows exponentially with the number of different plans offered by the healthcare payer and the number of states in which it offers plans. In addition to learning the process for handling all these ifthens and the details of each health plan, processors need to learn half a dozen different software applications or more and gain a deep and intricate understanding of health insurance. It s a hard sell to advocate investing in two to three months of training for a new employee in this role before they are ready to do the job. But this is a common challenge in the industry perhaps an inevitable one, considering the range of information that claims processors need in order to perform their roles effectively. The obvious business challenge is how to create a continuous onboarding experience for these employees that allows them to ramp up quickly, obtain training and coaching over time, and stay abreast of the changes in the industry as they occur. It s just one of the many challenges that exist in this new business environment. Creating that ideal onboarding environment requires analysis, organization and hard work but the potential results are truly compelling. A well-designed, continuous onboarding experience, utilizing an innovative learning environment, can result in significant reductions in training time and time to competency after training, as well as improved customer satisfaction. In short, current training programs can be modified so that the cart (product, system, and process knowledge) is not pulling the horse (resourcefulness, problem solving, and adaptability). Our experience shows that while job-related knowledge is necessary, higher-order skills and behaviors are the true differentiators for top performers. The revised program can be augmented by a realistic electronic practice environment that allows processors to practice applying their new skills, using all appropriate systems and tools, but without impacting production claims. Such environments can be created affordably, without the inflexibility and expense of simulations or replicas of the actual systems in use. Data Allows Us To Ask: Which surplus processors have proficiency with claims in the deficit queues? Claims Inventory Without Employee Readiness Data Processor Productivity Readiness gaps are discovered once claims begin to age in queue, creating risk for financial penalties for overdue payments. Aged claims initiate a reaction to shift processors work assignments based on anecdotal data. Processors are deployed on new queues with little to no preparation or understanding of their performance capabilities with those queues. Healthcare insurance claims processing divisions are marvelously data-rich. While past data reporting may not be predictive of future inventory spikes, it can outline quantities and categories of expected claims inventory. That data, combined with processor productivity rates, supports key workforce planning, such as how many processors are needed. When training acts as a strategic partner to the business, data describing employee readiness metrics can be aligned with surplus Can they be re-assigned immediately, or can they be cross-trained quickly? With Employee Readiness Data deficit Readiness gaps data is always available for proactive planning. Training is aligned with inventory categories (e.g., work queues) and can be deployed in short refresher increments based on inventory and need. Processors work assignments are based on quality scores in the practice environment for that work queue, which are predictive of accuracy with live claims. Strategic Partnerships between Business Goals and Training Programs existing data on inventory volume and categories. This allows for more informed workforce planning, particularly employee readiness planning. For example, inventory and productivity data alone indicate the number of processors needed to handle volume. But employee readiness metrics can identify which processors are skilled at handling which inventory categories, taking the guesswork out of estimates about how to manage specific work queues. 5

6 Claims Processing Cost Timely Payment interest payments Customer Satisfaction re-submissions Overall Accuracy returned for errors Overall Resolution time to close Quality error rates Productivity volume per hour Problem / issue resolution skills Compliance Process knowledge Product knowledge System knowledge Practice Time management skills Financial Objectives Strategic Objectives Tactical Objectives Performance Objectives Training Intervention After a thorough new-hire training process focusing on the development of key skills and competencies, additional training can be released in brief, targeted increments to keep skills fresh and to cover advanced processing needs. Whether these training increments are brief classroom sessions or online, self-paced lessons, they can be combined with the experiences acquired in the practice environment. This environment exposes processors to the range of if-then statements for a specific category, and demonstrating proficiency in the practice environment becomes a deciding factor for readiness to do the job with real customer claims. By aligning business goals and individual performance metrics with specific training and relevant assessments, clients can see at a glance: The competency gaps that need to be addressed with cross-training or up-skilling. How to fill those gaps by deploying the right training (aligned with business need) to the right employees. Learning Services a Partner in Payer Success Creating and implementing a solution that meets the objectives of healthcare payers, members, and providers requires managing people, processes and technology. Learning Services solutions help the organization and its employees develop the agility needed to provide exemplar performance in a dynamic and complex operating environment by creating a learning solution that is scalable, adaptable, accessible, and linked to business goals. Learning Services has worked with one of the largest healthcare insurers in the United States, with more than 1,000 processors handling more than 40 million claims per year. We helped the client re-align training to focus on the skills and behaviors processors need by keeping the focus on systems, products, and processes all while looking through the lens of truly performance-enhancing skills like analytical thinking, problemsolving, and customer focus. Our solution decreased presentation of information and increased hands-on practice with information. In addition, Learning Services has used rapid development techniques to create a practice environment for our client that is designed to teach the adaptability needed for the degree of change inherent in processing healthcare claims. Process improvements, regulatory changes, and system upgrades have little to no impact on the practice environment, eliminating most ongoing maintenance needs and allowing the client to focus on growing the environment and expanding processors ability to practice. It provides a way for processors to work with realistic claims, to learn how to process, to evaluate their accuracy and see the impact on customers without impacting production. This environment provides hands-on practice using the tools processors use on the job. Individual results are tied to quality performance metrics like procedural and financial accuracy, indicating readiness with much greater accuracy than multiple choice tests and other traditional training assessments. 6

7 Are You Ready? Learning Services can help you turn your uncertainty into an opportunity. With deep experience in the healthcare insurance industry, we understand the critical challenges you face in the times ahead. Our customized learning solutions will help you: Align individual and business metrics to ensure employee performance will help the business achieve its goals. Identify the employees behaviors that lead to success. Align existing training with those behaviors. Develop additional training to fill the gaps. Prescribe continuous learning paths to help prevent future readiness gaps. Collect the right data and report it in an easy-to-read dashboard. About the authors Lorne Hamilton is the Vice President of Sales in Xerox Learning. He has over 25 years of experience designing solutions to meet client business objectives and has worked with over 100 clients, many in the Fortune 200. Most recently, his focus in the healthcare payer and insurance industry segments has resulted in creating and implementing learning solutions to meet the industry s dynamic and diverse needs. Elizabeth Pearce is a Principal Consultant at Intrepid Learning, Inc. She has 20 years of experience working with clients on organizational and human performance and managing the development of learning solutions. She has a specialization in working with healthcare insurance clients on their unique needs. To learn more, visit or call Xerox Corporation. All rights reserved. Xerox and Xerox and Design are trademarks of Xerox Corporation in the United States and/or other countries. AC BR13048.