Most health plans have acquired and built disparate member eligibility and enrollment (EE) applications over time. Examples include Medicare, Medicaid, private exchange, public exchange (upcoming), group and individual market applications.

These EE software applications may run on different platforms, requiring multiple technical skill sets and results in underutilization of hardware resources. Over time, these member silos? result in duplicate records and information gaps in member history, creating extra processing requirements, additional operations costs, unnecessary benefit payments and possibly reduced health outcomes.

Health plans can improve financial performance and health outcomes by integrating member information across the enterprise.

The Masked Challenge

The Public Exchange presents an opportunity for health plans to rationalize the IT infrastructure, add flexibility and reduce operations costs. Using a flexible, rules-based and workflow-driven infrastructure, health plans can use this technology to configure the Public Exchange enrollment functionality, and then, using the same flexible rules and workflow-based infrastructure, modernize other eligibility modules over time.

This approach presents a low risk approach that allows a health plan to maintain control of the IT infrastructure and built out functionality that is consistent with strategic plans.

Public Sector leads the Way

For the past several years, the state Public Health and Medicaid programs have been, with the financial encouragement of the federal government, leading the way towards integrated eligibility. States have identified a primary flaw in their service delivery mechanisms in that the silos of information between eligibility systems for various Public Health and Medicaid programs is reducing the effectiveness of the multiple safety nets in place.

For instance, a homeless person is less apt to take medications as prescribed versus a person in a shelter or home. Solving the homelessness situation increases prescription adherence and reduces emergency room visits. This leads to lower overall costs and better health outcomes. Only a holistic and integrated view of a member can address these types of issues that the states are trying to address.

Opportunity Unfolds

Commercial health plans can use the same integrated eligibility approach to provide a single holistic view of a person's wellness activities, changes in health and healthcare plans, and care management program enrollment and progress. Implementing this integrated approach using rules and workflow-based tools will streamline the plans' technology footprint, provide for a single integrated source for eligibility and will result in increased member health outcomes and lower operational and program costs.

Shannon Glasscock - Senior Technologist, Wipro's Health And Life Sciences Division

Shannon Glasscock has over 20 years of public and private healthcare IT experience, including claims adjudication, eligibility and related administrative systems