When Holidays & Healthcare Open Enrollment Collide

Lack of transparency in health plans is enough to give most people heartburn.

Susan Taylor, VP and Business Unit Leader for Healthcare, Pegasystems

December 16, 2014

6 Min Read
(Source: <a href="https://www.flickr.com/photos/cynicalplanet/3063696588/"target="_blank">Ariel</a>/Flickr)

25 Years Of Health IT: A Complicated Journey

25 Years Of Health IT: A Complicated Journey

25 Years Of Health IT:
A Complicated Journey (Click image for larger view and slideshow.)

Holiday gatherings in my home are very traditional. Take our last Thanksgiving, which found us embracing such time-honored pastimes as watching the Macy's Parade while the turkey roasted, cheering for our favorite sports teams throughout the day, and pausing between bites and courses of dinner to talk about health insurance.

Yes, health insurance topics are right up there with the Snoopy balloon for my family on Thanksgiving. Maybe this is true at more tables nationwide, given how the Affordable Care Act and retail health have brought new importance and challenges to open enrollment season. But my family might be a bit different, considering most of us work in healthcare.

In our house, after the Thanksgiving dinner plates are cleared, we play a version of "stump the chump" using health benefits as the topic. As of November, those enrolled in January-effective policies (more than half of us) had been using benefits for 10 months of the year. Some may have seen their primary practitioner once or twice, while others, facing more significant health events, have required more frequent interactions. Everyone started the year with a more or less even playing field of cost sharing -- deductibles, co-pays, and out of pocket maximum payments (OPX).

Over pecan pie, we try to figure out the best course of action to take on health questions for the remainder of the year. By Thanksgiving, most have begun thinking about health needs for the coming year while reviewing health services for the past year -- looking at current health plan balances and trying to determine what's going on with our explanations of benefits (EOBs). Inevitably, there is data missing in the EOBs to describe the context of the claims processing and financial accounting.

What is that context? It's the simultaneous interpretation of the appropriate rules of up to six contracts surrounding one healthcare event: contracts between the individual with the insurer, the insurer with the organization (employer) sponsoring the individual's insurance, the insurer with the provider, the insurer with the state and federal governments, the provider with the state and federal governments, and last, the provider with the individual. It takes a lawyer to understand the complex context, and yet the summary of that reconciliation is what is supposed to be captured in an individual's EOBs.

[Adding even  more uncertainty: ICD-10 Delay Again? Don't Do It.]

A significant challenge facing the industry is that the systems health insurers use to process claims and produce explanations of benefits are configured in codes that have meaning only inside the system itself. Many of these systems are more than 20 years old -- dating from before "HillaryCare" back in 1993. The cost and organizational change required to replace them is enormous. Hundreds of millions of dollars are spent in the process, yet few are successful.

With the risk and cost of failure so high, health insurers look to leverage existing investments and add-on capabilities to make the contracts' rules more accessible to configuration and operations. They create automation and transparency around the black box -- automation that allows them to process claims more accurately and faster and transparency that provides service teams with information they need to be able to answer consumer questions when they're asked.

Take me, for example. I have dental insurance. I went to the dentist in September and have now received three bills from for the office visit and a single filling. Each bill referenced a different amount and, since September is now over 60 days ago, I have been informed that I am more than 60 days past due. What's going on? The dentist's revenue cycle management service (e.g., billing) simply issues a bill for any amount due. The system has no concept of shared financial responsibility and the possibility that the context of my bill is "incomplete." The system balances charges and credits but can't seem to keep track of the fact there are amounts that are "unknown," e.g., my responsibility -- the charge for the services less the discounted rates for my insurance and payments of my insurer. I have yet to receive the EOBs from my dental insurance company. It's going to take me an hour (and the dentist and insurance company an hour each) to figure this out. Sadly, that's likely to cost each party more than the amount of the bill. It would be far easier for the dentist's system to hold off on billing a patient until there is some clarity on what insurance is actually paying.

Now let's suppose the amount of this claim service put me over the limit on my deductible for the year. If so, then I should schedule every possible visit this calendar year -- or maybe not. If I blithely believe that the health plan will be picking up 100% of the charges for the services, I could find myself with an extra lump of coal in my financial stocking. It may turn out that the services I need actually allow for continued cost sharing, even after the limits have been met.


Picture this occurring in households across the country, and in homes where healthcare is not the family business. The results are confusion, frustration, and unhappy consumers trying to figure out and plan their healthcare needs. Many organizations serving those consumers are burdened with outdated systems that don't allow the organizations to provide the type of customer service needed, both from the consumer and the organizational standpoint. Considering my dental scenario above, profit margins are greatly impacted by organizations not having the type of infrastructure to simplify and streamline these processes so customer representatives can provide better levels of customer service more quickly. They cannot afford to be stuck in these scenarios.

In my family, we are lucky enough and healthy enough to be able to play this "game" and reconcile this "bit of fun." And for that we are thankful. We all look forward to the day when we have enough transparency and clarity on healthcare expenses and choices that we are required to invent a new game for holiday gatherings.

The owners of electronic health records aren't necessarily the patients. How much control should they have? Get the new Who Owns Patient Data? issue of InformationWeek Healthcare today.

About the Author(s)

Susan Taylor

VP and Business Unit Leader for Healthcare, Pegasystems

Susan Taylor brings to Pega her 20 years of successful experience with payer and provider technology and operations, most recently from Oracle Corporation. Prior positions include Sr. Director of IT and Operations, responsible for Harvard Pilgrim's enterprise business architecture and transformation initiatives, and founding VP at Allmedia Solutions, a clinical documentation company serving sub-acute care providers. Prior to that, Susan was a member of the technical research staff at Bell Laboratories where she developed rules-engines for integrated circuit routing. Susan has an MS CS from Columbia University and was 2010 AHIP Fellow. She has served on the board of professional organizations, including the Business Architects Association.

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