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HEALTHCARE ENROLLMENT SERVICES

 

Enrolling members and maintaining their eligibility files accurately is one of the most taxing, cost centric and important tasks for Medicare Advantage and Part D plans. Given the timelines, Medicare Advantage plans faces different but unique challenges in maintaining member eligibility data due to the complexity of the requirements and orchestration between enrollments, eligibility updates and reconciliation imposed by the Centers for Medicare and Medicaid Services (CMS). Acquiring and maintaining accurate eligibility information is critical to the success for the Medicare plan. Errors and inconsistencies in beneficiary information lead to costly mistakes eroding financial performance, undermining beneficiary satisfaction and exposing the plan to the risk of serious regulatory compliance errors. One of the most critical processes that plans must have to be compliant with CMS and ensure proper payment is the reconciliation of payments from CMS. Discrepancies in the data maintained by the plan and by CMS can often result in incorrect payments from CMS.

iSpace has developed a strong methodology and best practices surrounding Medicare beneficiary enrollment. iSpace enrollment services cater to the different stages of the enrollment process:

Healthcare Enrollment Process

 

Pre-Submission:

Maintaining accurate beneficiary eligibility information is crucial and impacts downstream processes. The pre-submission process is critical to the efficient and effective operations of the health plan. Enrollment data impacts many processes including Plan payment, PDE submission, Plan withhold processes and other data interfaces and interactions. Spending more time and validating data upfront using internal rules engine and the BQE process, helps improve the ROI across the enrollment process.

iSpace can help with the pre-submission process by bringing both technology and business process expertise. iSpace can start with the paper enrollment forms and help convert them to electronic data. Clients have leveraged iSpace mail rooms and data conversion technology to successfully convert paper forms to electronic data within 24 hours turnaround. Leveraging the work done for other plans, iSpace has built a rules engine that can interact with any technology to provide a validation layer to filter data elements in the electronic feed that need further work. Health Plan can then query CMS using their Beneficiary Eligibility Query (BEQ) process about the applicant eligibility. iSpace can help update the internal records with the information returned from CMS. Preliminary Data validation combined with the updates received from CMS results in the health plan maintaining accurate information. This information serves as the basis for cross verification of data, billing and settling claims.

Submission:

As part of the enrollment process, CMS communicates a more comprehensive report of all eligibility changes through a weekly and monthly Transaction Reply Report (TRR). The weekly TRR covers the processing week and the monthly TRR covers the payment processing month. The TRR is an important tool for health plans to capture changes to beneficiary, synchronize and stay consistent with CMS Data.

In order to expedite timely resolution of complex eligibility variances, iSpace can assist clients with reviewing variances that exist between CMS provided eligibility information and Health Plan data. Based on an accumulated set of best practices, and working with client processes, iSpace can work on any resolution action as needed. Variances are identified through various processes such as the Monthly Attestation Report, PDE rejections and routes. The types of variances that are reviewed can range from member eligibility to demographic information, as well as low income data, indicator fields such as Part A and B eligibility, and State, County, and Out of Area issues.

iSpace has extensive experience with different tools in this regard including Market Prominence, Info crossing etc.

As subject matter experts in the field of healthcare payer business systems technology, iSpace has achieved a market presence in enrollment processing. We bring expertise, customer service, best practices, innovation and exceptional people adding value to everything that we do with our clients, as well as a long and well-managed relationship history. We bring on table our expertise in development and services in the following areas –

  • Member Eligibility Verification.
  • Member Enrollment
  • Application processing
  • Enrollment reconciliation
  • Member Management
  • Payment reconciliation
  • Risk Management
  • Suspect Claims
  • Chart Analysis
  • Coordination of benefits (COB)

Post Enrollment:

As a best practice, verifying CMS data with the Health Plan's internal record each month ensures that correct information is used for eligibility determinations and invoicing, and validates the accuracy of payment amounts from CMS and beneficiaries. Starting 2009, all Health Plans need to call beneficiaries post enrollment and educate them on the plan benefits and other selections made. iSpace can assist Health Plans with the education calls to beneficiaries. Leveraging our onshore call centers, iSpace can make scripted calls to Beneficiaries and educate them on their chosen benefit plan.

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