Health plans must prepare for an influx of COVID-19 claims as this pandemic evolves. While the sheer volume of claims may not vary in the short-term, the nature of the claims will dramatically change. Claims characterized as emergent/urgent in nature, with high acuity and large-billed charges will surge.
In fact, eighty percent of payers expect a rise in claims after public health emergencies.[1] The increase in volume will mirror periods of open enrollment and will include an increase in questions about coverage, payment requirements, as well as increased member grievances. Additionally, health plans will see more than a fifty percent increase in member service needs, a similar volume as during open enrollment periods.[2]
We examine methods health plans can use to prepare for this imminent surge in both claims and member needs.
Consider Leveraging a Program Management Office (PMO):
Payers seeking to accurately plan and effectively execute upon a surge of activity should leverage a program management office (PMO). Effective PMOs are designed to provide structure and governance to drive timely prioritization and decision making, while building an infrastructure to enable swift and consistent delivery. Whether building a new PMO or re-purposing an existing structure, ensure foundational elements of a PMO are ‘right-sized’ to effectively manage surge capacity.
An effective Payer Surge PMO will have the following foundational elements:
Leveraging these foundational elements will allow payers to successfully address the anticipated increase complex claims and/or member service needs as a result of COVID-19.
Deep Dive – Examining the PMO and Current COVID-19 Dynamics:
Payer organizations should ensure the application of the foundational elements of high-performing PMOs to effectively manage anticipated surges. Specific considerations include:
Performance Management
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
Use existing reporting tools as well as situation-specific analytical resources to identify the frequency and type of unusual activity. Share real-time status with leadership and process owners as the situation unfolds so decisions can be made and action taken as opposed to dealing with a future unmanageable surge or backlog.
IMMEDIATE CONSIDERATIONS
- Review claims inventory reports and auto adjudication levels
- Evaluate staffing and surge timing for customer service and claims
- Monitor claims processing accuracy for COVID-19 claims and appropriateness of information provided to members on phone calls
Integrated Program & Change Leadership
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
As the operational shift unfolds, ensure that all stakeholder (customer, employee, vendor, shareholder) impacts are identified and addressed. Focus on communication, training, and support for employees which will translate to high service levels for customers.
IMMEDIATE CONSIDERATIONS
- Establish COVID-19 Action Teams or Steering Committees
- Provide reporting and surveillance to these teams for decision making
- Institute change management techniques for the 30-60-90-day period of COVID-19 surge and prepare for subsequent surges in Fall 2020
Processes, Methodologies, and Tools
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
Ensure existing processes (automated and manual) for “normal” occurrences are not interrupted. Quickly identify missing processes or tools required to manage new and unusual events and rapidly incorporate them into existing workflows.
IMMEDIATE CONSIDERATIONS
- Develop and implement new claims processing requirements and tools for COVID-19 claims
- Continue appropriate compliance and operational monitoring of non-COVID-19 processes
- Identify areas of operational slippage and institute corrective actions
Strategy Alignment, Prioritization, and Governance
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
The formation, management, and assigned responsibilities of the PMO should align with the overall strategy of the company and how risk can be mitigated in the short-term. It should be a cross-functional effort of all impacted teams – Claims, Member Services, Legal, Compliance, Supply Chain, Clinical, HR, IT, Finance, etc.
IMMEDIATE CONSIDERATIONS
- Evaluate COVID-19 surge strategy including impact to operations and staffing needs in the short term and on-demand for subsequent outbreaks
- Establish COVID-19 action plans and teams for impacted departments to plan for operational sustainment and quality
Executive Sponsorship
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
Ensure that the overall response is the responsibility of a key executive who actively and visibly leads the effort. The responsible leader should communicate the vision of the response, set expectations, and confirm that the overall team has the resources they need to ensure success.
IMMEDIATE CONSIDERATIONS
- Establish and charter an executive-level COVID-19 Action Team that has the ability to effectuate overall change management and receive and react to in-process reporting
- Set a communication strategy for internal and external stakeholders as to the COVID-19 response and go forward strategy
Culture
FOUNDATIONAL ELEMENTS APPLIED TO COVID-19 DYNAMICS
Use existing positive cultural norms and priorities to energize the team. Use this situation to model new behaviors and priorities to improve collaboration and performance post-crisis.
IMMEDIATE CONSIDERATIONS
- Encourage an empathetic and supportive culture within each of the operational areas to fortify the positive impact the plan can have in the COVID-19 crisis
Conclusion – Critical Considerations for the Current Landscape:
The COVID-19 pandemic will continue to provide new challenges to health plans and test their ability to react to the stress on their various operations. In closing, we want to provide several near-term actions for your consideration to prepare for today’s volatile environment:
- Charter a COVID-19 Executive Task Force: The Executive Task Force should help the business build organizational agility for resiliency as we navigate unprecedented times.
- Reset Operational Resource and Staffing Projections: It is critical to minimize the negative financial and human aspects of change in periods of crisis. Whether you are growing or contracting, it is vital to know your numbers, and your people, to survive.
- Make Affirmative Utilization Management Change: Institute necessary lifting of COVID-19 related prior authorization rules to allow for out of network utilization as well as appropriate clinical review of prospective treatment.
- Update Care Management Priorities and Processes: Perform risk assessment of member populations in SNP-related plans as well as Medicaid that have care management components to identify and prioritize “high risk for COVID-19” members.
- Establish a Cohesive COVID-19 Communication Strategy: When developing a communication strategy, consider target audience and stakeholder groups, various modes, and key messaging elements.
- Work Collaboratively with Pharmacy Benefit Management: As approved pharmaceutical care regimens come online and access to the same would be allowed, make sure that the PBM has arranged for the proper approvals and formulary treatment. Make sure that vendors such as PBMs have lifted necessary edits and relaxed prior authorizations and allow maximum days’ supply.
- Stage Claims and Customer Service Surge Departments: Run models to determine what the anticipated volume increases will be due to COVID-19 related activity and adjust staffing and resource ratios to allow for timely and accurate operational performance.
- Do Not Sacrifice Accuracy and Quality for the Sake of Speed: Establish appropriate and reasonable turn-around times and resource expectations to reduce the incidence of inaccurate claims processing or incorrect customer service communications.
[1] Healthy Payer Intelligence, 4/15/20.
[2] Ankura Disputes & Economics internal analysis.
© Copyright 2020. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals.
Ankura is not a law firm and cannot provide legal advice.
