Managing Employee Benefits is a Cyclical Process
But as a third-party administrator (TPA), it’s your responsibility to make that process as smooth and efficient as possible — for yourself, for the employer who’s entrusted you with its benefits administration, and above all, for the employee him or herself. To achieve that level of efficiency and service, it’s important to understand the different health data life cycle stages of an employee. In this post, we’ll explore these different stages in-depth and what the data produced in each stage means.
Note that these stages apply to all employees — whether they’ve already been an employee for years before your relationship with the employer started or if they were hired on mid-year. Even if the company doesn’t offer coverage until the employee has completed a certain length of employment, at some point these stages will commence. However, to keep things simple, we’ll explain them as though it’s the start of a calendar year and the employee is eligible for all available benefits.
Stage 1: Benefit Selection
This most often occurs during an annual open enrollment period when employees can sign up for different levels of health coverage including dental and vision amongst others. Depending on the organization, it may also be when a new employee is eligible to sign up for benefits. Employees will review the plan types and levels available and make choices based on their needs and circumstances. It’s a benefits best practice to pay close attention in this stage to understand what plans are the most desirable and why. More on this soon.
Stage 2: Voluntary Choices
Once primary benefits have been reviewed and selected, the employee will then review any voluntary benefits options that the employer might provide. These could include flexible spending accounts (FSAs), health savings accounts (HSAs), accidental death and dismemberment (AD&D), life insurance policies, different disability options, employee assistance programs, and more. As with the different levels of medical, dental, or vision plans, how employees utilize these benefits will be important to monitor during the year.
Stage 3: Consumption
This stage in the health data life cycle is simply the employee’s use of his or her benefits selections throughout the plan year. Employees that have selected FSAs and HSAs will make contributions to those accounts and use (or not use) their funds as needed. Employee assistance programs will be used. And while the hope is that insurance and disability programs won’t be used anytime soon, there may arise a situation in which an employee passes away or becomes injured. However, some of these situations also factor into the next stage.
Stage 4: Life Events
Another significant health data life cycle stage is life events. This might include anything from marriage or the birth of a child to an employee or covered family member becoming disabled or passing away. Changes will happen throughout an employer’s employee roster, so it’s important to be prepared to respond to change quickly as a TPA as well as monitor trends in life events.
Stage 5: Claims & Bills
This stage in the health data life cycle is less chronological and more ongoing. This is because employees will utilize their benefits throughout the year and file claims accordingly. However, as a TPA you’re likely familiar with the year-end crunch in which plan participants rush to get their claims in on time in order to get reimbursed during the calendar year and realize the associated benefits when tax season comes along just a few months later. In this stage, it’s critical to understand whose claims come in, what they’re for, how long they take to process, and what the outcomes are.
Stage 6: Next Best Action
Each of the preceding stages produced a significant amount of data about the plan participants and their preferences. They also produced data on how you were able to process those EOBs efficiently — or not. This employee benefits data is absolutely critical in understanding what matters to plan participants, the success of your employer and broker relationships, and even the long-term success of your TPA business. This stage more often occurs downstream as the year has progressed and participants have used their benefits.
The Process is Far from Perfect
While we’ve been able to break the health data life cycle down into tidy stages based on benefits, getting the data needed in each stage can often be challenging for TPAs and employers. There are a number of reasons for this.
First is that there is often a lack of integration between the many systems involved with employee benefits. For example, if your TPA doesn’t have a platform that integrates directly with an employer’s benefits carrier, participants would have to submit explanations of benefits (EOBs) to you directly via email, fax, or mail. While that doesn’t sound difficult, the issue lies in the sheer amount of time and effort needed to process those EOBs manually. Even email — the fastest of the three — requires one or more people to man an inbox or submission system and manage the influx of claims as they come in. Emails must be forwarded, attachments must be printed and stored, and responses must be issued. It can all add up very quickly.
Another reason is data loss. If you’re managing EOBs manually as we just described, there is a high likelihood that somewhere along the line, a claims processor will skip a submission, forget some important piece of information, or forget to send an email to another person involved in the process. It happens, and one time is one time too many. Participants are counting on you to substantiate their claims and complete the reimbursement process. If it can happen once, it can happen more times, and these slips can start to mount based on the number of claims processors working manually.
Everything is Connected
If the process breaks down in one area, not only will it lead to breakdowns elsewhere but it will also result in data problems. If EOBs are getting stuck upon submission, it may eventually create a data point downstream showing that employees aren’t using their benefits as much and could lead to the cancellation or downgrading of a benefit product. This is an extreme example, but its point stands: the health data life cycle must be as efficient as possible to ensure you and your partners are working with good data. And for you, that data leads to growth.
Using an automated solution that integrates with your benefits administration system allows you to seamlessly capture employee insurance logins and capture EOBs for timely claims substantiation and reimbursement. Over the course of a plan year, this translates into significantly improved efficiency by automating many of the manual tasks that slow TPAs down and prevent them from meeting goals and keeping partners satisfied.
Evaluate Your Health Data Life Cycle Stages
Take time to consider how your TPA approaches these health data life cycle stages. How are you capturing EOBs? How are they moving throughout your process? What do they say about your employer partners’ employees and their benefits preferences? What data do you have that demonstrates a greater interest in one product over another? Does the data show that the employer is offering a product that it could justifiably eliminate due to a lack of utilization (even if a fair amount of people signed up for it)?
This has a powerful impact on sales, too. If you grow through broker relationships, the information you gain through the health data life cycle can become a sales tool. For example, it might become clear through the data that the employer has an opportunity to increase its benefits offerings — perhaps offering higher levels of coverage. It will be beneficial to share this information with the broker that set up the relationship.
Put Data to Better Use with TPA Stream
TPA Stream is a health data integration platform that connects TPAs with the technology they need to work more efficiently and intelligently. If your TPA has been struggling with a lack of workflow automation, ease of EOB harvesting, or with securing new opportunities to work with more employers, we’re here to help. Our platform was built to help you make improvements throughout your entire organization, becoming more efficient, productive, and profitable.