by An-Chan Phung
In today’s competitive health plan market, payers are facing an environment ripe for disparate, incomplete, and duplicate information; yet they are under pressure to make better use of their data to drive higher ROI from sales, marketing, operations, and customer service. With a master data management (MDM) solution, health plans can break down the silos that hold this information to eliminate duplicates and create an accurate, complete picture of each member, gaining insight into new opportunities to improve member engagement and retention. Such a system can also provide transparency and empower payers with the skills and tools to maintain control of all the business rules and other decisions that drive the data governance process.
Following are a few examples in which a robust MDM solution – or the lack thereof – can make or break payers’ success.
Population Health Management
A focus on wellness can reduce cost for patients, hospitals, and payers. Health plans already have several means to do this, including utilization management, care and disease management, and complex case management. Many of these strategies, which may include encouraging diabetics to go for regular eye screenings or offering nutrition management programs to members with metabolic syndrome, have been shown to improve patient outcomes, thereby reducing cost for payers.
For example, Modern Healthcare reports that a recent CMS report “showed that per-beneficiary spending for consumers receiving chronic care management (CCM) services in the first six months of 2015 were $1,395, compared with $1,192 for those who received services in the first six months of 2016. In addition, over the second year of the experiment, CMS paid roughly $52 million in CCM fees and generated a net savings of $36 million, largely because those beneficiaries were less reliant on both inpatient and outpatient care.”
However, savings like these cannot be realized if the member data is full of fragmented, incomplete, or duplicate information. It’s important for payers to have complete information on their members to ensure that those with particular health conditions are enrolled in the proper care management programs, to see which members regularly go for annual physical examinations, and to analyze information such as readmissions, prescription adherence, and so on. A robust master data management tool provides clean data for such analytics purposes.
Provider List Management
A survey from the American Medical Association found that “more than half of U.S. physicians (52 percent) say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians.”
As of early 2018, however, these out-of-date lists have the potential to become more than an inconvenience for patients; they could mean steep fines for payers. “The Centers for Medicare and Medicaid Services put new regulations into place this January that levies fines against insurers of up to $25,000 per beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for errors in plans sold on the federally run insurance exchanges in 37 states,” reports Healthcare Finance News. These penalties are “specific to Medicare Advantage programs and policies sold through Healthcare.gov,” and align with existing regulations that govern group plans. The Summary Plan Descriptions (SPDs) required under ERISA (Employee Retirement Income Security Act) have long mandated that employees be able to access up-to-date provider directories, supported with fines for non-compliance.
Consumer expectations about the frequency with which provider directories should be updated have changed significantly. The federal mandates have been supplemented by state legislators. Many states have now established regulations for how often such provider directories must be updated – ranging from annually (Connecticut) to monthly (Idaho) to, in some cases, even weekly (California).
The only way for payers to stay ahead of the curve with such stringent regulations is to employ a master data management system to ensure that such provider information remains current.
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