State-based Health Plan Improves Membership Visibility, Insights and Data Quality

Overview

A state-based health plan, offers a range of plans to commercial, ACA Exchange and Medicaid to approximately 100,000 members. Each of these lines of business had its own membership process involving a variety of internal systems, external vendors and CMS. This disjointed structure of multiple systems and sources for membership data adversely impacted the company’s data management efforts by offering very limited visibility into the membership process and prevented leadership from seeing a complete and accurate understanding of key membership analytics. It also posed significant risks to the overall data quality of the health plan’s digital records. This combined lack of insights and quality control meant increased financial risk, inaccurate quality of care reporting and lost opportunity to improve the member experience.

Business challenge

The company’s chief information officer (CIO) and their team quickly recognized the numerous challenges presented by multiple membership sources and systems and began looking for a single platform to give the company complete visibility across disparate systems to better understand membership analytics to improve operations and make better business decisions. Members frequently hopped back and forth between Exchange and Medicaid plans, resulting in duplicate membership files that gave an inaccurate view of gaps in care and other quality measures—lowering HEDIS scores and health plan reimbursement. To correct this inaccurate, inconsistent and duplicate data, the health plan needed a data reconciliation process that would reconcile data across multiple sources and use complex matching to detect any potential duplicates. This included summary and detail-level reporting on errors, reconciliations and membership data to consolidate duplicate files and resolve other quality issues.

Read more about how this state-based health plan tackled the lack of accurate membership analytics within and across business segments prevented the company from uncovering insights to improve operations and enhance the member experience.