AI Powered Automation Puts Benefits Enrollment in The Fast Lane

Posted by Patrick Bores on August 18th, 2023
Patrick Bores
Patrick is the Chief Information Officer and product and technology development leader with over two decades of experience in the healthcare industry. As a healthcare automation expert, he spearheads innovative AI/ML solutions to improve accuracy, efficiency, and cost-effectiveness. He graduated from the University of Minnesota in Computer Science and is a Certified Information Systems Security Professional.

The business of benefits is a never-ending exercise in data wrangling. Each year, healthcare insurers and third-party administrators (TPAs) are inundated with thousands of member enrollment event submissions, which come from a wide range of sources in various formats. TPAs, especially, are constantly challenged to collect and interpret all of this data, ensuring every detail is plugged into its proper place, quickly and securely. It can be a tedious, time-consuming process when performed manually by employees, and the parts that can be digitized test the capacity and precision of existing IT systems. Mistakes can and do occur, often resulting in slow turnaround times and dissatisfied clients.

The data-crunching grind of benefits administration is nothing new to TPAs, a fact that has led many companies to accept it as the imperfect nature of the business. On the other hand, some administrators are shunning such complacency and harnessing advanced technologies to put their operations in the fast lane. New solutions in the form of automation and artificial intelligence are making the business of benefits faster, more accurate, more cost-effective, and improving the customer experience for everyone involved.

New Era, New Problems

While the digital age has undeniably ushered in some impressive speed and efficiency gains for businesses of all types, it has also created new layers of complexity. Ironically, such a wide assortment of platforms and systems across different companies can bog down a process if they can’t work together harmoniously. Such is the problem with benefits administration. TPAs rely  on various intake andprocessing systems, all with different requirements for the data they’ll accept.

Meanwhile, benefits enrollment data from employer groups arrive in a myriad of formats, whether standard, semi-standard, or non-standard, ranging from Excel spreadsheets and 834 files to emails and faxes. The data is rarely configured exactly how the TPA’s system wants to receive it. Thus, the job often falls to IT staff to engineer bespoke technical workarounds, or to data entry employees to read, reformat, and input data manually.

It’s a process prone to bottlenecks and data entry errors at any time of year, but the challenge doubles during the frenetic open enrollment period. Many firms are forced to redirect existing employees and/or hire seasonal staff to manage the ballooning workload, adding to the time requirements and costs of administration.

Beyond the immediate urgency of data processing demands, inefficiency also undermines a company’s ability to grow the business over the long term. When a TPA is barely able to manage the deluge of data it already receives, adding new clients is a risky proposition. And when members can’t get their ID cards in a timely manner due to technical issues, they become dissatisfied with their payer.

A Bridge to Bigger and Better Things

To this point, many TPAs have been stuck on what could be viewed as a digital island. Like most companies, they’ve adopted the core technologies enabling them to store and work with digital data in-house, but a lack of interoperability keeps them disconnected from their customers and business partners. The flow of information between them is obstructed, and their methods of conveyance (i.e., manual data entry and remediation) are antiquated. These limitations are holding TPAs back from greater efficiency and growth potential.

In a perfect world, employer groups would provide all enrollment information exactly as the TPA’s system requires it. But since that day will never come, the realistic solution is to automate the process of data intake and conversion.

A well-designed automation solution can bridge the divide between employer groups and TPAs, utilizing existing vendor networks to facilitate connections, and enabling interoperability with legacy systems. When all incoming enrollment data is funneled through an automated platform, TPAs no longer need to rely on their IT and enrollment personnel to reformat data or upload the information by hand. Equipped with artificial intelligence (AI) and optical character recognition (OCR), the automated platform should be able to capture data from multiple source formats and reconfigure it as necessary for submission to the TPA’s core system. More than capturing and submitting data indiscriminately, AI is capable of comparing the data to a master copy of the enrollment, detecting errors and making changes automatically.

To summarize, an intelligent automation platform can provide TPAs with a clean, accurate data stream in far less time, with little-to-no human intervention. That, in turn, can unlock some powerful business advantages.

Leaner, Faster, Stronger

How exactly can TPAs capitalize on the efficiency of enrollment automation?

For starters, it has the potential to dramatically lighten the workload of TPA staff members. For example, IT staff can spend less time fixing data transmission problems and more time on proactive,
business-enabling activities. Meanwhile, the enrollment team, freed from endless hours of data entry, can focus on service-oriented tasks requiring a human touch.

Of course, automating tasks that used to require armies of employees will also present opportunities for labor savings. This is especially true when it comes to the busy open enrollment season, as automation may help TPAs avoid the costs of adding and training temporary staff.

With faster turnaround times, fewer errors, and the ability to integrate with clients’ system requirements, customer service stands to improve as well.

Finally, as automation allows TPAs to process more enrollment data with improved service quality, it reduces the risk of over-commitment. In other words, they can confidently expand existing client relationships and take on new accounts to keep the business growing and thriving.

Thinking Ahead

It’s a gradual transition, but businesses in every industry are using automation and AI to remove labor-intensive manual processes from their operations. In doing so, they’re realizing unprecedented productivity, greater customer satisfaction and lower costs. It’s time benefits administrators capitalized on the same opportunities. Those who do will undoubtedly become the preferred providers in respectively the years to come.

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