Blog Post

How Open Enrollment Automation can improve employees' and health payers' bottomline

Blog Post

Will Roberts Profile

Will Roberts

Senior PMM


In this three-part series of blog posts, we address why open enrollment is so important to employees, their employers, and health insurance plans. Unfortunately it is also a process where employees may delay or avoid critical steps that are intended to maximize their use of their benefits for better health outcomes and lower out-of-pocket expenses. In this third post, we will discuss the ways that employees can choose and change their Primary Care Physician (PCP) and reap the benefits from working within their in-network choices for both their standard and specialized care. In the first post, we addressed the basic details of open enrollment and the differing benefits needed for different age groups, particularly people approaching 26 and 65. And in our second post, we talked about the information that is gathered during open enrollment, specifically Health Risk Assessments (HRA) and how it is used to inform employee care management for this critically important task. 

Open Enrollment: Details

Open enrollment season is the only time that employees can sign up as new clients or simply renew their benefits plans with the companies they work for (barring certain circumstances such as a new job, marriage, birth, adoption, or divorce). Despite the fact that the benefits enrollment process occurs every year at the same time, many people simply let their insurance choices carry over from year to year without reviewing their options, wait for the last minute to try and enroll and make changes in the 11th hour, or else miss the deadline for enrollment altogether.

Employee engagement around open enrollment is something that can and should be actively maintained and encouraged throughout the year by both a business and carrier so that open enrollment is just one part of your employees’ experience around their overall health and wellness. It’s so important to maintain high levels of engagement because your open enrollment process is just the beginning of an ongoing health management process where your employees partner with their health plan to fully use their benefits to improve outcomes and lower costs. The open enrollment process is also just the beginning of an ongoing healthcare management process that includes all your employees, especially when it comes to maintenance and preventative care.

Choosing a PCP is an essential part of the ongoing healthcare management process that a health plan offers their clients—but the Journal of American Medicine Association reports that it’s a key relationship that has been on the decline. If the process of PCP choice was as easy to research, select, and contact as looking for a restaurant on the internet, employees would be more willing to take the time to choose. But it’s a manual process, current systems are hard to search, and they have little to no rating systems which is a great way to make PCP selection frustrating.

With Ushur’s Invisible App™, you can easily build simple, intuitive process workflows that use automation to encourage more employees to choose a PCP as part of their open enrollment journey.  This not only establishes a medical partner in each employee’s well-being. It is an easy way to build an understanding of the wellness and financial value of always seeing care providers that are within the health plan’s network. Employees, their employers, and the health plan benefit from the ongoing involvement of a PCP who has been vetted for their medical expertise, along with being more affordable.  

Primary Care Physician (PCP) Selection

Some people forgo choosing a Primary Care Physician (PCP) completely. In fact, every year the number of people who have chosen a PCP has decreased, including people in their 60s.1 While the reasoning behind the decrease can be appreciated, namely healthy customers perceive they don’t really need to go in to see the doctor, it is also not the best decision for their long term health nor optimized for cost savings; a substantial proportion of medical costs are for preventable conditions.

Having even one visit with a PCP is a best practice because it establishes a relationship and sets a foundation for future visits; whether for preventative care or because of illness.

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And studies show that patient satisfaction increases when patients have chosen a PCP to work with,2 whether they visit the doctor regularly or not.

Unfortunately, most technology solutions offered by benefits packages makes choosing a PCP difficult and time consuming rather than a time savings. Instead of recognizing a member’s location and physician care needs, and then delivering relevant results, choices are listed in pages and pages of physician choices and offer no way to know which one provides the best care for a member’s specific requirements. If a member does decide to check a physician rating system, it’s another manual process in which they must leave the insurance provider’s site, inadvertently leading individuals to a PCP or specialist that is out of network and therefore more costly.

In-network Steering

Surprises are fun and exciting if it’s your birthday, but they’re not so great on a medical bill. The past year has been rife with these kinds of nasty surprises. As many as 18% of people use out-of-network providers and feel blindsided when hit with larger bills because of it. Because of the negotiated agreements between health insurance plans and their network care providers, in-network physicians and facilities cost less for the employee, the employer, and the health plan. For example, using an in-network doctor for an annual physical might involve the employee carrying a $40 co-payment. But going to an out-of-network doctor could result in that same employee paying 20% to 35% of the full-cost of the medical service, a difference that could translate to hundreds of dollars and an impacted level of employee satisfaction.

The best way to prevent this very expensive and unexpected error is to make sure that customers can easily access their network provider list whether they are at home, or on the go, perhaps even in a doctor’s office, about to schedule a procedure. And make it easy for the employee to see and understand the difference in cost if they choose to go out-of-network for care.

Currently, searching for network care is cumbersome and vague and offers few guarantees of coverage accuracy. Additionally, if there are differing levels of benefits offered, as is the case for many HR departments in many organizations, the employee has to know which plan they have in order to know which network of caregivers they can use. This unwieldy experience leads to costly employee billing surprises, dissatisfied clients, and time-consuming health plan call center operational costs. Customer frustration quickly rises as their employees have to waste time on a call for something that they should be able to quickly locate with their smartphones. For a small business especially, those benefits administration frustrations can erupt into a nightmare for the HR team

Ushur Customer Experience Automation™ Enables Decision Making

Ushur’s proprietary automation technology, Invisible App™, uses artificial intelligence (AI) and machine learning (ML) to create a personalized experience for each employee regardless of the communication channel. Drawing from their own information and the plan that they have chosen, Ushur’s UX-first technology platform allows employees to search for PCPs, facilities, and services, quickly and easily. Employees only revert to querying the health plan call center for more unique, complex inquiries. And even then, with the AI-driven Invisible App™, repeated queries on the same topic can be identified and addressed via intelligent automation and proactive employee communication. Altogether, the end goal of this automation lifecycle is to decrease health plan call center volume in order to drive cost savings and increase accuracy.

By drawing on each employee’s personal benefit information, members can ensure that their care provider choices remain in-network, with verified quality and lower cost. They can easily choose their PCP and even make an initial appointment. Using Ushur’s cloud-native Invisible App™ to make the research process easy and simple encourages employees to take full advantage of their benefits.

By drawing on each employee’s personal benefit information, members can ensure that their care provider choices remain in-network, with verified quality and lower cost. They can easily choose their PCP and even make an initial appointment. Using Ushur’s cloud-native Invisible App™ to make the research process easy and simple encourages employees to take full advantage of their benefits. 
Ushur’s Invisible App™ unblocks the confusion around the open enrollment workflow, making it the start of a healthcare management process that individuals can extend into their daily lives to improve their health, and ease their benefits information collection. For workers and HR professionals alike, it will pay off to simplify this entire process when it comes time to complete an HRA and gather other documentation. Thanks to Ushur, the stressful time and extreme effort associated with trying to choose and maintain physician care and services that are in-network can be a theme of the past.

Ushur’s Customer Experience Automation™ platform helps to create an employee experience that makes full use of their benefits for a better life. 

  1. Declining numbers of Americans have a primary care provider
  2. Managed Care, Primary Care, and the Patient-practitioner Relationship
  3. An analysis of out-of-network claims in large employer health plans

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