Managing customer experiences at today’s healthcare crossroads

American healthcare is at a critical juncture and is in need of automated services to provide services to a growing system, says Pegasystems' Elizabeth Hart.

Commentary - There have been countless stories in the media about individual healthcare and many are questioning what it all means. Most recently, the majority of the questions ponder proposed legislation that would require individual healthcare coverage. A recent Washington Post article noted, "It [proposed healthcare bill] sets up a new competitive health insurance market giving tens of millions of Americans the exact same insurance choices that members of Congress will have. A new Newsweek poll shows 81 percent support for a ‘new insurance marketplace -- the Exchange -- that allows people without health insurance to compare plans and buy insurance at competitive rates.’”

There is no doubt that individual healthcare is coming in some form, especially as some states have already implemented mandates. When this happens, it opens up a world of opportunity and issues for brokers, agents and payers alike. Not only will there be a huge influx of queries from individual customers, but brokers will need to partner with providers to ensure the right information is going to the right customer at the right time. In addition to the uptick in customer activity, there will be much more paperwork, processes and regulations that must be accounted for.

Customer experience is not where it needs to be
Historically, healthcare payers have had a captive audience and required little by way of customer service to ensure their renewal rates. With the onset of individual healthcare, these same organizations are now finding themselves behind the eight ball, needing to demonstrate their ability to not only be responsive to requests, but to be seen as proactive wellness organizations, looking out for the best interests of their customers.

At the same time, the payers will be forced to be even more responsive to the brokers who are selling their services. If they are unable to turnaround quotes, for example, in a timely manner, they will lose out on a huge opportunity. Brokers will also need to have payer information at the ready to tackle the numerous queries they are bound to receive on an ongoing basis. In the very near future, these healthcare organizations as well as the brokers they partner with will find themselves in a mad dash to catch up or find themselves out in the cold.

What can be done/what is available to me today?
Business Process Management (BPM) enables the automation of goal-directed processes across people, systems, departments and even partner organizations. In essence, it can link the multiple systems for each of these care management groups and drive care for individual patients while simultaneously managing targeted programs for larger population groups. The technology continuously monitors patient, payer and industry events and guides users through processes, presenting relevant data intelligently when needed or requested. In this way, the technology ensures that plans and brokers are consistently providing the highest quality care programs and the programs are being continuously tailored to individual patients, even as their health conditions change.

BPM systems also automate menial tasks like sending correspondence and wellness materials, providing multi-channel notifications to wide-spread patient-support networks, updating plans and keeping systems synchronized. This dramatically improves organizational productivity because brokers have the most up-to-date, accurate payer information at the ready and can get information and/or quotes to customers in a timelier manner. The end-result equals happier customers and a faster turnaround for new customer engagements.

Health organizations leveraging BPM technology have made impressive achievements. Reports note that these organizations are reaching 100% accuracy in authorization processing; 55 percent reduction in the cost per case with a similar drop in case handling time; user training has been cut by a third, and processes have been moved quickly to the web for patient and provider self-service. Additionally, the integration and availability of data along with facile, real-time targeted reporting, enables effective physician benchmarking and peer-review which is a very successful method for changing provider utilization and reducing medical costs.

These organizations have also gained the ability to quickly roll out new programs. No longer constrained by a dependence to IT or to system-vendors, BPM business owners are able to add enhancements to systems themselves, and can easily test which strategies are most effective. Business owners report changing BPM rules in as little as ten minutes, and selectively deploying new changes to pilot groups so that program efficacy can be easily evaluated. BPM’s self-documentation capabilities also prove invaluable when brokers must show compliance during routine regulatory reviews and high-stakes legal engagements.

American healthcare is at a critical juncture, as is the role and value of healthcare insurers and brokers. Healthcare reform is under discussion, but neither its specifics nor its effectiveness is yet known. To prepare for the influx of individual enrollment requests, healthcare payers and brokers must ensure their customer service is up-to-par or face an unending amount of customer churn. The sure bet is wide-spread deployment of BPM technology beyond administrative functionality, such as basic claims or address changes, but rather to focus on areas where it has started to produce transformational results – better relationships with customers, better partnerships with payers and brokers as well as increased sales and renewals.