BLOG: Q&A - How health plans can simplify the benefit plan process

Health Plan Alliance



These days, health plans are mired in complexity and inefficiency as they struggle to configure and deploy new offerings for their increasingly demanding customers. Healthcare industry veteran, Mohammed Vaid, CEO of Simplify Healthcare, shares his perspective and talks about how some health plans are seeing real success with automation, achieving compliance and growth, and saving significant dollars.

Alliance: What are some of the main inefficiencies health plans are dealing with?

Vaid: The entire benefit plan process—from developing the product to implementing it—requires a lot of member interaction. Members submit a claim, search a health plan’s website to try to determine their benefits, or call the customer service number to see if something is covered, etc. On the provider side, they do the same thing, calling different channels to try to find out benefit information internally within the payer space. 

The problem is that operationally, most of this plan creation is being done manually. People are relying on Excel grids, Word documents, emails, handwritten change logs, color coding, and tracked changes. If you look at the amount of manual work people are putting in and the amount of data being replicated across the enterprise, it doesn't surprise me how many issues exist today. When you talk about health plans trying to grow, they're always restricted by speed-to-market issues and trying to compete from a price point perspective because of the manual nature of their process.

Alliance: Do most health plans consider this business as usual?

Vaid: CXOs probably don’t wake up worrying about their process because it still works, it’s just really inefficient. Some health plans have tried to go down the automation path, burning through $75 to $125 million, spending 4-5 years on implementation, but they’ve been unsuccessful and are often gun shy to try something new. 

Simplify Healthcare has been in the healthcare benefit business since 2008, but in the past three years we’ve seen a significant uptick in the number of RFPs that have been submitted in search of a better process. Health plans are recognizing that benefit products are getting more and more complex and that members and large group employers are increasingly demanding, requiring additional flavors of product offerings. As a result, the market is becoming more competitive and health plans are realizing that the current method of operation is simply not sustainable. 

I asked one health plan how they would react if their sales team came to them and said they could grow the business by 20 percent. They said their system would “break” because they’re already maxed out. Health plans need to figure out an effective way to automate if they want to stay competitive and grow.

Alliance: Why haven’t past automation efforts worked?

Vaid: The benefit plan development process often starts with an Excel grid, then someone figures out what the product needs to be. Next the claims person configures it in the claim system, the marketing communications team generates an ANOC/EOC and a summary of benefits. Then SBC and regulatory documents are created manually or via some glorified mail merge document generation tool. When health plans try to automate this process, I’ve seen two different problems:

  1. A health plan’s IT team decides to build something from scratch because they believe their situation is unique—that there’s no solution in the market that can address their specific business process—but it doesn’t work.

  2. Health plans think they can use a business process management (BPM) tool to automate because they’ve seen it work in the financial sector. But our world is very different. It’s heavily regulated, there’s a lot of pressure from internal teams and external partners in terms of what needs to be defined, there’s actuarial consideration, and there’s inherent complexity in the process of managing the sale and the quote-to-card workflow. 

A conventional software development lifecycle approach cannot handle the dynamic nature of this business. By the time you’ve completed the build, it's already outdated because new regulations or new business needs have cropped up and a developer has to make changes again. Maybe some health plans with deeper pockets can afford to spend $150 million to automate, but 95 percent of the market can’t.

Alliance: If these approaches aren’t working, what do you suggest?

Vaid: Health plans need a solution that is tailored to their specific needs. Whether someone selects our eBenefitSync solution or someone else’s, it’s important to make sure that your own business users can configure the system without coding. They should be able to configure a new benefit plan, or modify it, or create incremental building processes, where no two areas have to rekey or reinterpret the same information again. If that entire process can be handled by the business team with minimal engagement or dependency on the development staff, that’s ideal. 

Health plans should also focus on solutions that can be implemented in three to six months so they can get some successes under their belt and move forward in an iterative fashion. 

Alliance: Are there success stories out there already?

Vaid: Absolutely. I may sound like I’m tooting my own horn, but one of the things that differentiates Simplify Healthcare is our clients’ success. We’ve built our platform from the ground up to address benefit plan management needs. Our solutions are highly customized for the health plan space, not for specific plans, so health plans can configure their own rules and workflow. We help our customers during the implementation process. In one client example, we migrated 20,000+ benefit products at a fraction of the cost of other solutions within six months. It’s an iterative process and some implementations take longer, but health plans won’t have to wait 3-5 years to see results.

The other piece is the entire document generation process because the compliance piece is crushing payers. Right now so much manual intervention is required, but if health plans could automatically generate documents using business rules from a single source of truth for their benefit products, load all their information once, and disseminate it across the enterprise using a business rules model driven approach, that’s a formula for success.

Alliance: What’s a typical lifecycle like for your customers? 

Vaid: We work with health plans to understand their most critical pain points. One needed to load the claim system with benefit data faster. We automated that portion and they reduced errors by 90 percent and effort by 65 percent in the first year. 

Another payer was trying to build up their source of truth and generate documents, but the compliance aspect was debilitating them. We automated that process in six months which has reduced risk of penalties significantly and enabled them to achieve 100 percent compliance.

In addition to eBenefitSync, we have a specific offering for Medicare called eMedicareSync. We can get a plan up and running in 3-4 months, which allows clients to do the entire CMS PBP bid submission and auto-generate all the documents with the click of a button. 

Payers are always busy, and we at Simplify Healthcare take pride in the fact that we have a team of subject matter experts who are able to help our customers achieve success. 

Alliance: Tell us about your work with Alliance member health plans? 

Vaid: We currently partner with four Alliance member health plans. One has been with us for two years and is leveraging our eBenefitSync solution to automate their MA PBP and ANOC/EOC and SB process and for their commercial business generating SBC, SPD, EOC, booklets and riders.

The other three newer Alliance clients are using eMedicareSync, our Medicare Advantage (MA) configured version of eBenefitSync that provides a turn-key end-to-end MA product configuration (including automated CMS PBP submissions) and a document generation solution (ANOC/EOC, SB) that improves accuracy, timeliness and reduces effort/cost by 75 percent. We’re excited to continue to deliver value by planning to help them integrate their source of truth benefits data into their claims, CRM, portal and sales systems. We will also be helping them with their provider data and contract management and value-based reimbursement needs.

About Simplify Healthcare

Simplify Healthcare is a part of the Health Plan Alliance Group Purchasing Organization and is offering Alliance members exclusive savings. Alliance members can learn more about Simplify Healthcare and download their contract for member savings from Simplify Healthcare's vendor directory listing 





Mohammed Vaid

Mohammed Vaid is the CEO / chief architect at Simplify Healthcare. He is a technology industry veteran with extensive experience of delivering innovative technology solutions to leading ISVs and Enterprise customers. He has driven more than 50 different application and product development initiatives with 45,000+ hours of solution, design, and technical oversight. Under his leadership, Simplify Healthcare established itself as a market leader in its space.

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