Payers: Think holistically – Break Data Silos to Drive Efficiency, Savings, and Better Member Service

If complexity is the enemy of execution, a great many healthcare payers seem to be embracing their most formidable foe. Taking a fresh look at opportunities to simplify data-dependent processes could unlock breakthroughs in service and cost reductions.

To be fair, the business of healthcare insurance is undoubtedly – and to some extent, unavoidably – complex. A host of separate workstreams, from prior authorizations and claims processing to utilization and disease management, must collect and manage mountains of patient and provider data on a daily basis, a reality that creates infinite possibilities for bottlenecks and human error. In an attempt to refine these processes, the payers’ various departments often implement separate software solutions, solving some problems but creating others in the form of data siloes and duplicated efforts.

While it may not be readily apparent, this fragmented, myopic approach to process improvement silently undermines companies’ goals of maximizing efficiencies and cost savings. To improve business performance and provide the best possible member service, payers need to consider a holistic approach to aggregate and optimize data across the enterprise.

The source of many problems

In today’s digitally enabled world, the free flow of electronic data is the lifeblood of any enterprise, and nowhere is it more critical than in the healthcare industry. Yet, the proliferation of isolated, disjointed software “solutions” (it’s not uncommon for payers to work with 20 or more different technology vendors) prevents the synergies that characterize best-in-class organizations.

This disconnectedness causes or contributes to a host of issues:

• Duplication of data: With healthcare data flooding in from all directions (medical records, claims, eligibility files, etc.) in different formats into different systems, payers often wind up with several versions of the same file floating around. Disorganized data creates chaos, confusion and inevitable delays.
• Human errors: Most payers suffer from a shortage of skilled staff such as clinicians, examiners, and member support personnel. Already under pressure to do more in less time, overworked staffers take longer and make more mistakes when they can’t reliably access clean and coherent data.
• Poor member service: Delays and errors in authorizations and claims processing frustrate members and can even prevent them from receiving the urgent medical care they need.
• Higher costs: Less efficient workstreams require more workers in each department. Meanwhile, departments often pay multiple technology/software vendors for services that overlap and could be consolidated.
• Disgruntled employees: Inefficient workstreams also exacerbate the problems of employee burnout and turnover, further increasing costs for hiring and training.
• Damaged provider relationships: Payers need to maintain a strong network of healthcare providers on their plans, but (like members) providers are dissatisfied when slow service and mistakes prevent them from getting paid.
• Gaps in security and compliance: Payers must ensure every technology vendor meets their standards for protecting patient data and complying with regulations. But the more vendors a company employs, the harder this process becomes, creating dangerous vulnerabilities and potential fines from regulators.

A big-picture approach to optimization

While healthcare payers may be aware of these pervasive problems, many have come to accept them as unfortunate facts of life. Without a centralized authority and an overarching vision to lead change across departments, they may fail to see the forest for the trees. The fact is, however, that modern technology offers opportunities to replace outdated, isolated systems with holistic solutions that break down data silos and drive efficiency through the organization.

Here are three recommendations to help payers move toward this less restrictive, more collaborative way of working:

1. Establish a cross-functional team: Call it a taskforce, a steering committee or a center of excellence, but the idea is to bring people from different departments together to work toward a common goal. These representatives should compare notes on the workflow challenges facing their respective departments and develop specific plans to tackle them together, to the benefit of all stakeholders.

2. Conduct a thorough software audit: Part of the taskforce’s job should be to identify every application involved with workflow optimization, understand how it works, its benefits and limitations, and how much it costs the company. It’s likely the team will find that separate departments are using different tools (and paying multiple vendors) to do very similar jobs. This uncovers opportunities to use fewer products, simplify processes, renegotiate vendor contracts and cut costs.

3. Seek outside expertise: In these kinds of wide-reaching transformational efforts, it often takes more than the in-house team to deliver real change. A technology partner with broad healthcare expertise and experience can view the organization through an objective lens and offer unbiased guidance to achieve best-in-class interoperability and workflow management. In some cases, they may offer solutions the in-house team would have never considered. It’s critical, however, to choose a partner that can meet the organization where it stands today, proposing realistic solutions that are grounded in the company’s current challenges and can integrate with existing frameworks.

What success looks like

As healthcare payers develop their own vision of a fully integrated healthcare information system, they open the door to a wide range of potential improvements in speed, accuracy, service and cost. While the possibilities are plentiful, a few common examples could include:

• Consolidating enterprise content management. With a single online platform that can leverage AI to create richer content and additional data insights, payers can eliminate the duplication of data and streamline coordination between departments. The result: the ability to connect, manage, view and share accurate patient data when and where it’s needed.
• Combining paper and electronic workflows. Even in the digital era, many healthcare interactions still occur via paper forms, and payers must be able to manage them effectively alongside electronic documents. With technologies like rapid scanning, optical character recognition, AI and machine learning, today’s automation solutions can bring together paper and digital processes on the same platform to ensure consistency in how business rules are applied.
• Integrating claims operations end-to-end. From document intake, to claims review and approvals, to financial transactions with patients and healthcare providers, a more holistic approach to automation can ensure these systems operate in lockstep. With the same clean and consistent data flowing through every step, staff members encounter far fewer exceptions to slow them down.

Ongoing improvements produce long-term benefits

Beyond the use cases mentioned above, healthcare payers’ potential to streamline operations through automation is near-boundless, and new opportunities will continue to present themselves over time. In any case, achieving automation at scale shouldn’t be seen as a one-off implementation; rather, it’s as an ongoing strategy that evolves with the needs of the organization, the state of the industry and the regulatory environment. Most importantly, process optimization should be a shared responsibility, requiring an enduring partnership between the company’s various functions, its employees, and the technology partners they choose.

When it all comes together, the effects can be profound: more consistent and accurate data, fewer errors and improved service to patients and providers, stronger security and lower operational costs. In the long run, those outcomes signify meaningful progress toward a more efficient, effective and affordable healthcare system for all.

Contact us today to streamline workflows, reduce costs, and enhance service quality—transform your operations and unlock greater efficiency.