Like many AI-enabled researchers, I turned to LLMs to understand the meaning of ‘transformation-led transition’. I received an apt response: Transformation-led transition refers to the process of moving from one state or phase to another, driven by a significant change or evolution in the organization, product, or process. This transition is often triggered by a need for adaptation, innovation, or improvement."
This definition clearly articulates what payers seek to achieve in the mid- and long-term. Let’s examine its key terms before we delve into the specifics.
Payers are at the cusp of technological advancement. They seek to leverage best-of-breed, cutting-edge AI-powered solutions and cloud scalability without disrupting their core operations. There's a significant need and urgency to transition from their current state of using legacy systems to a future state with AI, cloud, and modern solutions.
To understand their need for adaptation, innovation, and improvement, consider the example of member enrollment. New-age members expect payers to provide the same levels of service and transparency they experience with their retail or ride-share apps. Questions like "Where is my order?", "Is it delayed?", "Where is my cab?" and "How much will it cost me?" are answered right when the engagement begins. Members expect the same when enrolling for health plans, too.
Achieving this is crucial, but it is a balancing act. Payers must ensure business continuity while realizing efficiencies that validate the business case.
There are several ways to approach this balance:
(a) Run major transformation programs, improve technically, and
achieve a certain efficiency level.
(b) Engage BPO partners who can run operations with the current
set of technologies and achieve cost benefits.
(c) Choose BPaaS, where a payer engages with a partner who can
simultaneously transform technology and transition operations.
This is where Infosys Helix delivers significant value, enabling
organizations to achieve efficiency gains of 30%-40% across the
entire program.
Let’s break down what makes this possible. Key credentials for a
successful BPaaS vendor include a deep understanding of the
process and key technical capabilities, providing the latest and
greatest technology to ensure enrollment success, and the ability
to execute operations effectively. All these credentials are
explained below.
Key Technical Capabilities Utilized by Payers
- Applications are received through various channels (online, paper, phone, etc.).
- Initial data capture and validation occur at this stage.
- Detailed member information, including demographics, contact details, and health history (if applicable), is collected and verified.
- Members are assigned a Primary Care Physician (PCP) based on location, health plan, or other criteria to ensure continuity of care.
- After collecting and validating all necessary information and assigning a PCP, the member is officially enrolled in the health plan.
- Communication with newly enrolled members includes welcome packets, benefits information, and PCP introductions.
- This sets the stage for ongoing member engagement.
- Premium payments from members, including billing, payment processing, and discrepancy handling, are tracked and reconciled.
- Issues with incomplete or unsuccessful enrollments (e.g., missing information, declined payments) are identified and resolved.
- This step can loop back to Member Details or Enrollment Intake as needed.
- Continuous interaction with members is established to promote health and wellness, provide support, and ensure satisfaction through newsletters, reminders, and health tips.
- Data analysis identifies trends, measures performance, and improves processes.
- This includes enrollment rates, member demographics, and utilization patterns.
- Visual representations of data insights are created to facilitate data-driven decision-making.
With advancements in AI/ML, these capabilities are now enhanced for smarter decision-making. For instance, Optical Character Recognition (OCR) technology has streamlined the intake of paper forms. By leveraging traditional ML models, the system can recommend new plans or suggest changes to existing benefits, enabling members to select options that best suit their needs.
The Success of Enrollment
The success of enrollment hinges on several factors, with seamless member experience during and after enrollment being paramount. Technology plays a critical role in ensuring this experience meets expectations. At Infosys Helix (www.infosyshelix.com), our journey began with a clear vision: to make technology accessible, empowering payers to focus on their core process functions. This eliminates concerns about system maintenance, compliance updates, or scaling demands during open enrollment.
Infosys Helix is designed with a digital core and composable capabilities at its heart. As a platform, it is built with robust integration capabilities (Fig. 1). This allows it to integrate seamlessly with existing technology landscapes.
Banking on the maturity of cloud technology and the advancements in AI, we’ve embedded an AI-first approach in every aspect of our platform. This is seen in features like:
- Universal Search: As a core digital function, it enables member search using a single attribute, significantly saving time and improving efficiency.
- Member PCP: It facilitates member assignment to Tier 0 & 1 Providers, reducing travel time, decreasing churn rate, and improving Net Promoter Score (NPS).
- Next Best Action: It provides agents with system-generated recommendations based on historical context, standard operating procedures, and precedents.
- Anomaly/Fraud Detection: This flags potential issues based on historical data, rules, and patterns.
Execution at scale
With a presence in 47 delivery centers across 16 countries, infosysbpm.com has over 200 satisfied customers and a strong track record of executing operations effectively.
Contact us to learn how HealthCare BPaaS can add significant value to your transformation-led transition.
