Health Insurance Best Practices

Proven Health Insurance Leading Practices to Adopt

  • Best Practices (#199) / Health Insurance / Sales & Business Development

    Best Practice (Good)
    Use a scorecard system for qualified leads based on their likelihood to purchase an insurance policy. Have sales representatives prioritize the effort and time allocated to each lead based on the likelihood of purchase.
    Typical Practice (Bad)
    Allow sales representatives to choose whom to call at their own discretion with no guidance provided by management or the lead research and generation team.
    Benefits: Segmenting leads based on likelihood of purchase ensures that sales force staff are devoting a proportionate amount of time and effort to sales leads. This cuts down on low-value added work and increases the likelihood of a sale.
  • Best Practices (#200) / Health Insurance / Sales & Business Development

    Best Practice (Good)
    Define and continuously measure a standard set of sales representative performance metrics and provide frequent (weekly/monthly) updates on performance levels across the sales organization.
    Typical Practice (Bad)
    Have sales force managers may hold ad hoc weekly or monthly 'huddles' to discuss sales force performance due to non-existent or non-standard KPIs.
    Benefits: Allows for improved visibility of individual sales representative performance and allows sales managers to identify key differentiators between high and low performing sales staff. Also increases accountability for sales representatives.
  • Best Practices (#201) / Health Insurance / Network Development & Management

    Best Practice (Good)
    Develop channel partner loyalty and incentive programs to identify key channel partners that generate a relatively large amount of revenue through their channels. Communicate with those "high-value" partners to develop long-term, sustainable relationships.
    Typical Practice (Bad)
    Review channel partner performance on a quarterly or annual basis to identify the best performing channel partners and extend or terminate relationships based on performance findings.
    Benefits: Provides channel partners with additional incentives to distribute health plan products and ensures that top-performing partners are retained while low-performing ones are terminated or notified of unsatisfactory performance.
  • Best Practices (#202) / Health Insurance / Network Development & Management

    Best Practice (Good)
    Foster continuous communications with in-network providers, including face-to-face office visits and frequent email contact to update providers on issues such as new administrative procedures (especially as they relate to claims processing, payments and patient no-shows), clinical advances, quality assurance and legal matters.
    Typical Practice (Bad)
    Communicate with providers monthly through email to update them on legal and quality assurance issues. Create an email template to reduce the time required to draft and send emails to in-network healthcare providers.
    Benefits: Improves provider retention and overall relationship quality and keeps them informed on any legal or administrative changes that could affect their office or facility operations.
  • Best Practices (#203) / Health Insurance / Network Development & Management

    Best Practice (Good)
    Use a third party license verification service to ensure that all network healthcare providers have the appropriate credentials required by the health plan.
    Typical Practice (Bad)
    Use in-house contracting and licensing specialists to verify all network healthcare provider credentials.
    Benefits: Mitigates risk related to human-error, employee turnover and workload burdens and allows the health plan company to focus on more high-value tasks such as business development, customer service and network development/management.
  • Best Practices (#204) / Health Insurance / New Business Processing

    Best Practice (Good)
    Reduce instances of policy rescissions and post-claim underwriting activities by ensuring that insurance applications are completely clear to prospective plan members and conducting a fully-realized underwriting process during the initial application phase.
    Typical Practice (Bad)
    Provide incentives to underwriters for the number of policies rescinded and claims denied. Carry out routine underwriting activities during the initial application process and then perform additional underwriting during the claims process to ensure that plan members are eligible for claimed benefits.
    Benefits: Decreases expenses related to post-claim underwriting and premium refunds. Also improves customer service levels by reducing instances of policy cancellations (upon policy cancellation, all member premiums are refunded and the former member is forced to pay all medical bills out of pocket).
  • Best Practices (#205) / Health Insurance / New Business Processing

    Best Practice (Good)
    Implement an underwriting automation system that automates simple underwriting cases so that costly underwriting staff can focus on complex cases and other high-value tasks. Review productivity reports in real-time and modify underwriter behavior as necessary.
    Typical Practice (Bad)
    Have underwriters manually perform every aspect of the underwriting process, reviewing and making decisions on cases running the gamut from very simple to highly complex. Generate productivity reports at a set time interval (weekly, monthly) to review Underwriting staff performance.
    Benefits: Greatly reduces underwriting quote cycle time for simple cases while simultaneously freeing up underwriting staff to focus on complex applications and cases. Real-time reporting capabilities allows managers to continuously improve underwriting staff productivity.
  • Best Practices (#206) / Health Insurance / Member Services

    Best Practice (Good)
    Segment plan members based on demographic information (age, location, plan-type) and send correspondence (through email or traditional mail) on issues such as plan benefits changes, account balances, upcoming deadlines, local regulatory information and new in-network providers on a monthly or bi-monthly basis. Personalize all correspondence as much as possible (member name, location-specific information).
    Typical Practice (Bad)
    Send standardized correspondence to all plan members using email (or traditional mail) templates only when necessary to communicate account balances or upcoming deadlines.
    Benefits: Reduces instances of customer inquiries to member services call centers by pre-empting customer questions through email or mail correspondence. Increases customer service levels by personalizing member correspondence and overall information level regarding plan benefits, account status and network information.
  • Best Practices (#207) / Health Insurance / Member Services

    Best Practice (Good)
    Identify which types of services policyholders call the most often for and arrange the most in-demand options first on the IVR menu.
    Typical Practice (Bad)
    List all policyholder options in IVR menu so that policyholders can choose which IVR decision tree to be routed to.
    Benefits: Decreases IVR call abandoment rate by making the common options easily accessible to customers. Also reduces overall time customers spend in the IVR, whether the IVR resolves their issue or they are transferred to a live representative.
  • Best Practices (#208) / Health Insurance / Claims Processing

    Best Practice (Good)
    Educate providers thoroughly on methods for effective patient registration and data collection during office visits, providing them with a comprehensive picture of how an insurance claim is processed by the carrier and the consequences of inadequate patient data collection on the front-end. Require that providers allow returning patients to review all of their information (address, employment, insurance account, etc.) for accuracy before each visit.
    Typical Practice (Bad)
    Rely on providers to capture patients’ data using a one-off, unique method and contact them during the claims management process to correct incomplete or incorrect information. Simply ask returning patients if any of their account information has changed since their last visit to ensure that their information is up-to-date.
    Benefits: Reduces claims processing cycle time and administrative cost per claim by ensuring that healthcare providers accurately and thoroughly collect patient information. Also improves timeliness of outgoing provider payments by reducing instances of claim rejections and postal returns on patient invoices.
  • Best Practices (#209) / Health Insurance / Claims Processing

    Best Practice (Good)
    Verify patient insurance information before they arrive for their appointment, usually 3-5 days beforehand. When patients arrive, all that is necessary is to have them verify the information is correct.
    Typical Practice (Bad)
    Begin verifying patient's insurance information when they arrive for their appointment at the physician's office or healthcare facility.
    Benefits: Reduces claims processing cycle time and administrative cost per claim by ensuring that patient insurance information is correctly input. Also reduces the average time taken to submit claims.
  • Best Practices (#210) / Health Insurance / Medical Management

    Best Practice (Good)
    Create a set template for a general form that will standardize the information routinely requested from providers regarding common prior authorization submissions.
    Typical Practice (Bad)
    Implement unique submissions processes for different types of prior authorizations based on the type of service being requested.
    Benefits: Reduces prior authorization processing cycle time by making the submission information more accessible to prior authorizations staff. Decreases denials on the basis of incorrectly submitted information on the part of the provider, which reduces upstream rework and manual efforts related to information reconciliation.
  • Best Practices (#211) / Health Insurance / Medical Management

    Best Practice (Good)
    Track trends in denials of prior authorizations and learn the nuances of submission processes for each payer. Forecast which prior authorization submissions will get denied and focus on identifying and streamlining procedures for those types of prior authorizations.
    Typical Practice (Bad)
    Re-submit claims for medical care that requires prior authorization with third-party payer when it is denied or sent back with edits.
    Benefits: Increases prior authorization submission approval percentage for providers, ensures staff is aware of the most efficient ways to submit prior authorizations for approval, and allows providers to provide higher quality customer service to their patients.
  • Best Practices (#212) / Health Insurance / Medical Management

    Best Practice (Good)
    Ensure that your electronic medical record (EMR) system has a data input, or migration, template to enable your data to be uploaded in a consistent and compatible format. Also provide document & data management employees with a "dictionary" providing information on the desired input for each field.
    Typical Practice (Bad)
    Allow groups across different organizational areas or geographic regions to input and migrate data using their own, preferred format and rely on document & data management employee training and "tribal knowledge" to determine the desired input for each field.
    Benefits: Ensures that data is input in a correct, uniform and compatible format. Reduces difficulty of training new employees on EMR data input and migration.
  • Best Practices (#213) / Health Insurance / Medical Management

    Best Practice (Good)
    Implement collections processes (e.g., incurred late fees, overdue notices, telecommunication reminders, emails) based on how delinquent the bills are, rather than the fact that they are delinquent. Implement different strategies for the 30 day, 60 day, 90 day, 120 day mark, and so on. Patients whose bill is delinquent 90 days are 55% more likely to pay their bill than patients who are delinquent for longer periods of time.
    Typical Practice (Bad)
    Implement standard collection processes for delinquent bills, regardless of how many days they are overdue, with a cut-off number of delinquency days that will designate the bill to be sent to a collections agency.
    Benefits: Reduces the patient billing cycle by specifically targeting delinquent patients based on the likelihood of their bill resolution. Collections processes can be customized to the delinquency level, indicating the need for a more aggressive collections strategy.

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