GLENDALE, Calif. – April 3, 2024 – Member enrollment sits at the foundation of value-based care. Enrollment is the inception point of membership management and a source of truth to ensure a great experience and customer satisfaction for your members. An enrollment process should be streamlined, transparent, and, with advances in technology, largely automated. In fact, member enrollment data should be driving value across multiple business units across your enterprise-wide environment, including sales, claims, risk, clinical, quality, and compliance.

The reality is that member enrollment functions can become complacent and accustomed to working around constraints that gradually degrade efficiency and effectiveness due to a lack of investment in enrollment operations and systems. Instead, they construct processes to navigate workarounds and bolt-on software to fill gaps they otherwise couldn’t overcome. Frequently, enrollment teams have been feeling the symptoms long before they are able to make the case for change.

Warning signs you’re past due for a change

There are several signs that are seen time and again from payers during an AEP season that are signaling the time for change.

One of the areas we come across frequently is the need to employ additional, temporary staff or leverage third-party services organizations to tackle manual, repeated tasks during an enrollment season. These can range from managing application entry, imaging or scanning application data, managing the maintenance or creation of correspondence, outreach to call center support to verify information, or working with external sales partners to qualify or quantify data, among others. The need to scale headcount during AEP implies the function’s enrollment platform lacks the automation capabilities available in newer systems. The cost of this headcount should be considered when evaluating the total cost of ownership of “business as usual.”

Another sign is applying “band-aids” to your core enrollment solution or crucial third-party platforms to manage CMS chapter regulatory changes. CMS regulatory changes happen frequently and could impact enrollment operations and maintain compliance with CMS. Some enrollment functions can only navigate these situations by deploying a third-party solution as a quick fix “band-aid,” which is a sign their current solution is not flexible or scalable to manage regulatory changes on demand.

Data, data access, and data transparency are also key signals to enrollment functions that it’s time for a change. Are enrollment functions struggling to track member progress or need multiple reporting tools across the member lifecycle just to share information about a member internally?

Data transparency and data integration can significantly impact member experience on the front end but in a challenging enough environment I’ve seen this impact a health plan’s ability to submit enrollment data on time and manage membership data integrity to downstream business functions and processes.

Staying ahead of change

The best way to build, scale, and maintain a leading enrollment operational process is by constantly evaluating core solutions to manage your operations. Value-based care organizations should be evaluating the market at least every three to five years and consider whether they are still achieving the ROI promised back then.

Operational business leaders need to weigh functional and technological advancements with business impacts. These include functional metrics such as processing time, accuracy, and automation, but as important are the potential impacts to corporate strategies on member engagement, data interoperability, downstream partners, customer satisfaction, STARS, as well as user experience of the enrollment platform itself.

Forward-thinking investments need to add speed and precision to operations and enhance real-time decision making. When considering legacy systems versus new technology, ask yourself if this solution is or would be a driver of operational efficiency. Does it provide insights in real-time or on-demand to support critical decisions in enrollment, such as making last-minute strategic changes or analyzing redundancies in operational processes? Transformational investments need to score highly on these investments to maximize downstream success.

Next, enrollment teams can review downstream solutions and plan to remove redundant systems, lowering the overall cost of IT management and maintenance, as well as bolstering the argument for change.

Starting the innovation journey

Embracing innovation over legacy solution complacency requires an organization to deeply understand its operational challenges to drive the biggest business impact from change.

First, operational leaders should whiteboard processes across their member operational areas and vendor landscape end to end. This means stepping back and understanding holistically the member journey from the start of the sales process, as well as the maintenance and management of core systems. Do you have a core engine driving your enrollment processes? Are you integrating with multiple vendors for application consumption, as well as internal teams to drive and intake data? How are you communicating with beneficiaries, external vendors, and downstream partners to get the data needed to ensure you are remaining compliant with CMS?

When whiteboarding operations, consider processes from the perspective of a member, system end users, and leaders. Enrollment leaders need to understand different user personas and roles, how they best fit within the solution, and how to empower them with a system aligned to what they are trying to accomplish.

Enrollment leaders can then start to map out gaps in automation and data, starting with CMS integration, managing CMS touchpoints, and addressing changes from CMS. Leaders can map the enrollment process to determine which are automated, which require someone clicking a job to run it, and which require multiple steps or manual workarounds.

Enrollment functions should strive to provide digital simplicity to business users and leaders. By understanding user experience, enrollment teams can automate based on user personas.

Next, enrollment leaders can empower their organizations to accept a digital journey using artificial intelligence (AI), machine learning (ML), and natural language processing (NLP) to address these gaps. By understanding the user experience and their processes by persona and journeys, health plans can implement AI and ML to remove redundancies or manual processes, translate CMS regulations, or enable better forward-thinking decision making.

Enrollment operations are complex, include a latticework of complex integrations across third parties, and operate on strict regulatory timelines. However, in value-based care, enrollment and enrollment data are too crucial to the organizational mission – and organizational performance – to grow complacent.

Value-based care leaders understand that by staying ahead of change and starting their journey with a holistic view of their operations, they can build a culture that embraces innovation.

To watch the recent Reveleer webinar “Why it’s time to Invest in Enrollment Operations: How technology is shaping the member lifecycle,” please click below.

About The Author

Manny Alonso, Vice President, Product Strategy & Solutions - Enrollment & Membership