“We’ve always done it that way!” This is something that many people don’t want to hear. It doesn’t automatically shout “I’m willing to try something new”, that’s for sure! Sometimes we get complacent and the thought of trying something new is exhausting. However, in business, it is necessary to keep changing, reassessing, and creating new products or services, so you don’t get left behind.
For many of our clients, one of the hardest things we come across is getting them to change their mindset about their core system. In our world that core system is their claims adjudication system. As you know this is the system that is working daily to process claims, both big and small, for all your members, so yes, it’s a very important system. However, once a client adds an online enrollment and eligibility system to their software portfolio that new system should now become the core system of record.
Why is this change necessary?
Eligibility is really at the core of paying claims. If someone is not active, not eligible, termed, on leave, changed plans, etc., that affects how a claim is paid. Without eligibility data, you can’t pay claims. Therefore, it is very important to make sure that your eligibility system becomes the core system of record, so accurate eligibility data can feed directly into your claims adjudication system, and claims can be processed correctly and efficiently.
What if I have an urgent enrollment?
I know what you’re thinking, sometimes it’s urgent and we need to get someone into our claims system immediately. That is fine, so here is what you do.
Schedule a file feed from your eligibility system into your claims system more than once a day to alleviate as much manual processing in your claims system as possible.
Make any urgent changes in both systems at the same time so you don’t forget one.
Periodically audit both systems by using the reconciliation tool in your online eligibility system.
Change is good!
In most cases, changes or slight modifications to processes can bring about tremendous growth both individually and for your company!