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Commercial to Medicare Advantage: Supporting members through the health insurance lifecycle

Supporting members through the health insurance lifecycle

5 min read


Commercial to Medicare Advantage: Supporting members through the health insurance lifecycle

Convey Health Solutions

This post is sponsored by Convey Health Solutions.

As more Americans age into Medicare, health plans that support the commercial and employer group insurance markets are consistently working to transition those retirees to their government-sponsored Medicare plans during the next phase of their lives.

A variety of factors play into this brand-loyalty strategy, and “one important factor is member experience,” said Ameerah Murray-Whitaker, Vice President of Product and Service Delivery for Convey Health Solutions. Plans can improve member experience through the transition to Medicare Advantage (MA) and beyond. By ensuring optimized administrative processes, health plans can readily manage the complexities of the highly regulated Medicare markets and avoid confused and disappointed members.

Plans that administer MA in-house often struggle with administrative processes. They are finding that in most cases, the investment and time required to make improvements is far greater than the effort required to select an outsourcing partner.

The health insurance sector continues to lag behind most other US business sectors in terms of productivity improvements, according to McKinsey. These kinds of administrative and tech shortfalls contribute to between $760 billion and $935 billion in unnecessary expense annually in the US health care system.

Adding costs is a concern in the competitive, low-margin MA marketplace. In the Medicare open enrollment period for 2020, one significant trend was that 83% of consumers selected plans with $0 premiums. However, any growth in membership by offering these popular plans with inefficient operations may be temporary.

When optimizing operations, it is not advisable to simply transfer the solutions and processes that worked successfully for commercial plan operations into MA operations. Doing so puts compliance in jeopardy and introduces workflow inefficiencies that compromise member experience and quality ratings — consequences that can reduce revenues from CMS.

Recognizing the problems with adapting existing processes, some plans have chosen to go it alone and develop custom-built technologies to support their own internal processes. But in most cases, this mindset is also short-sighted, resulting in near-term improvements but an inability to keep pace with change long-term. The result is a much larger investment down the road. 

“Although payers can benefit greatly from partnering with MA solutions vendors, one of the major challenges they face is finding purpose-built technology that supports strategic goals without sacrificing compliance or efficiency,” Murray-Whitaker said. “Payers often take a piecemeal approach and end up interfacing with 20 or more vendors, while also adding bolt-on solutions in-house for anything their vendors’ platforms do not support. The result is unnecessary complexity and cost.”

In contrast, working with a trusted, single-source partner that specializes in MA can ease this pain while maximizing efficiency.

An end-to-end Medicare solution

“The first step should be to identify a single platform that is designed for the MA market, can efficiently and effectively integrate to a variety of health plan partners and will support the payer’s other offerings, including supplemental benefits,” Murray-Whitaker said. The resources required to navigate regulatory and compliance challenges make it especially critical to identify a vendor who provides deep government expertise along with a managed services model to help support the highly regulated MA market. 

Vendor evaluations should include an understanding of the following:

  • Management of pre-enrollment through enrollment
  • Integration to CMS
  • Ability to support marketing
  • Billing, invoicing, and payment processing
  • Grievance and appeal management
  • Claims administration and encounter data reporting
  • Management and processing of both inbound and outbound mail
  • Member services and customer experience technology

Where to start?

Investing in and implementing an alternative solution to serve the MA market can seem like a daunting task. Starting small and building a platform component by component is not the answer, as this approach may ultimately result in operations being painted into a corner, requiring even larger investments in the future.

Health plans choosing a sole-source partner to support their Medicare programs should consider several factors. Look for deep experience in the government markets, a stellar reputation, demonstrable experience in compliance, and effective support. After implementation, Murray-Whitaker said, “the vendor should have redundancies and recovery protocols that ensure any unforeseen issues are easily identified and corrected.” 

The resulting solution should assure MA plans they have reduced risks and established back-end processes that will serve the growth in their MA business, as fewer touch points means less exposure to variability. In an end-to-end environment, software updates in one component will not cause another part of the system to fail. Point-to-point functionality throughout the plan ecosystem will mean greater functionality overall.

Many plans do not think of proactively swapping out software as a forward-thinking business decision. However, a ready-to-implement solution that specializes in MA, complies with all regulations, and relieves cost and complexity, can give plans more resources to put toward innovation. This will help them stand out, keep members happy and ensure they are providing the best care possible at every stage of the member’s life.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans. Convey provides plan and member management, supplemental benefit management and advisory solutions for the rapidly changing health care world. Learn more.