Tuesday, March 25, 2014

3rd Reason Why Health Insurance Exchanges Will Continue Floundering in 2014

In two previous posts I offered a 1st reason and 2nd reason why I thought the deployment of Federally-facilitated Marketplace (FFM) and many state run exchanges would continue to flounder in 2014.

Now that we are near the end of the first open enrollment period for “Obamacare” I’m going to outline the 3rd and final reason why I believe health insurance exchanges (HIX) will continue floundering into 2014 and likely beyond.

Those Stinkin’ Changes Have Messed Up My Eligibility and Billing!

Now that millions of people have enrolled, all subsequent transactions will be change transactions; or “corrections.” And there’s a difference between corrections and changes. I’d venture to guess that the majority of new enrolees are just getting to know where they stand in terms of member cards, eligibility at the doctor’s office and what they must pay every month in terms of premiums. And any errors are being discovered. Moreover, a certain percentage of people will drop out, stop paying their premium and will need to be cancelled. People will get married, divorced, have kids, age out of commercial plans and into Medicare, etc., etc.

But the FFM and many state exchanges have struggled and continue to struggle with exchanging enrolment transactions with Qualified Health Plans (QHP’s.)  Even plain, old vanilla “834 add transactions” have created heartburn. Anyone who’s spent any amount of time in IT should clearly understand that adding something to a system is usually quite simple to accomplish; but changing something that already exists is often problematic. Ans processing retroactive additions and changes present an especially challenging demand. The architecture of the FFM, where the FFM is considered the system of record but the QHP systems where the actual meat and potatoes of enrollment and eligibility processing are completed, demands precise, consistent and timely exchange of data. I don’t believe this is happening on a consistent enough basis.

Follow-On Effects of Corrections and Changes

So the downstream impact caused by faulty or improper corrections and change transactions is the 3rd reason why exchanges will continue to flounder in 2014. Billing and member eligibility can easily get screwed up creating additional administrative impact to providers and QHP’s. For the remainder of 2014 and throughout the 2015 open enrollment period, expect to hear about – and perhaps witness first hand if you purchased coverage via an exchange – just how solid and accurate enrollment corrections and changes are being originated by the FFM and state exchanges.

For more information on health insurance exchanges and other health IT topics, be sure to follow me on Twitter.

Sunday, March 23, 2014

The Downside of Not Working in a Co-located Team

Working remotely – typically from one’s home – offers many benefits, productivity improvements and direct cost savings that are simply not available when working in an office co-located with your team mates under the gaze of management.

Previously I provided a post on The Downside of Co-located Teams. To be sure – and fair – there are certainly downsides to working remotely. Over my 25 year career in IT and consulting, I’ve worked from home quite a bit with my longest stretch being the most recent 2.5 years. Here’s a list of what I consider some downsides of working at home:

1. Out of Sight – Out of Mind

Probably the number one drawback for remote workers is they are not physically visible to management and executives who typically have control over one’s destiny at the company. Being seen at your desk early in the morning and/or late at night, whether you’re actually working or not, can positively color others impression of your work habits and value to the company.

2. You May Start to Work Too Much

Without the physical separation a daily commute inserts between your work and home life, certain personalities may go overboard on the amount of time they spend working and encounter difficulty separating their private life from their business life.

3. Picking from the Grapevine

You don't get face time with your coworkers, so it is more difficult to find out about new projects you might be interested in and upcoming changes and events that may impact you and your career.

4. Ease of Access to Others

When working remotely, reaching out to a distant co-worker involves making a phone call, sending an email, an IM or some other method rather than just walking over to their desk.

5. Family & Home Interruptions

Remote workers with nearby significant others, kids and close friends may be more easily distracted when these loved ones just barge into your home office and distract you from your obligations.

6. Stress on Relationships

Studies do say that “Absence makes the heart grow fonder.”  If you’re in a relationship with another person(s), seeing too much of that person(s) can certainly add stress.

7. Free Snacks and Meals

The leftover bagels, fruit trays and remnants of sales lunches are not available to remote workers. Moreover, those occasional pizza parties and other free meals at the office are unavailable.

8. Varied Lunch Partners

The camaraderie and social aspects of dining with team mates is not readily available to remote workers.

9. Community Service

Many organizations place a high value of employee community service. Remote workers may be prevented from participating in certain service events like heart walks or require extra effort to participate in events like food and toy drives.

10. Loneliness

Certain people – especially extroverts – can find working remotely to be an isolating and lonely existence. Pretty much all of the above items – if not consciously acknowledged and addressed by some means – can lead to a sense of isolation and loneliness.

12. Office Infrastructure and Supplies

Remote workers typically don’t have ready access to copiers, printers and office supplies. Some companies also don’t provide much, if any, assistance in regards to desks, chairs, proper lighting and other office amenities.

But Maybe Not?
Depending on the distance to your office, whether you live with others, and whether or not your entire team and all the 3rd parties your team interacts with on a regular basis are located in the same physical space, many of the above points may not apply. And there are many ways to ameliorate or obviate the downside of working remotely. In a future post I’ll share some ideas and tips that have worked for me over the years.

In the meantime, be sure to check out “Why Working at Home is Both Awesome and Horrible”

Friday, March 21, 2014

The Downside of Co-located Teams

There's been a lot of talk about how valuable it is to have team members co-located in the same physical office space. While there’s no doubt that proximity can foster exchange, requiring people to work in an office vs. remotely from their home or other location has many drawbacks that I think far outweigh the potential benefits of co-location.

Here’s a list of reasons against co-locating team members that I hope all executives and managers promoting co-location have carefully considered. I’d like to hear comments.

Master of My Domain

When working at home, the worker is the master of his or her domain and has much greater control over all of the following focus-busting realities of working in a co-located space:

1. Interruptions – Just as proximity can enable random positive interactions, it can also facilitate non-productive interruptions.

2. Office Noise – is very distracting. The solution for many is to wear headphones and listen to music. In my opinion, people wearing headphones are not approachable.

3. Unproductive Breaks – Taking a break at home is way more productive than at work. Food and drink are typically more readily available. Tossing in a load of laundry or taking care of a quick personal/family task energizes and can remove a pending distraction to make one more focused on work.

4. Forced (phony) Interactions – People are less likely to make small talk and engage in non-productive chit chat. At home I don’t have to worry about being waylaid on the way to the bathroom.

5. Gossip – are much less impactful at home. My experience is that spreading gossip is typically a random event that may be considered a crime of opportunity. That opportunity is somewhat removed at home.

6. Food Smells – can make some people sick to their stomach. How does one escape these at work?

Does anyone think working in the office improves work-life balance?

Work-life balance is one of those areas where many companies give lip-service but do not actually support.

7. Family care and Events – are easier to attend when one doesn’t have all the overhead of travel.

8. Sustainability – is all the rage. I can’t think of one aspect of sustainability that is improved by requiring people to co-locate. More gas, more waste, more space, more energy are used.

It Costs the Employer More…

9. Costs – office space and office equipment are not inexpensive.

10. Moves – Constant reconfiguration and the inevitable moves are a huge distraction and cost a lot of money.

And it Costs the Employee Even More…

11. Clothes – Not having to purchase a work wardrobe is an important benefit of working remotely.

12. Commuting – the shortest of commutes can add 1 hour a day to one’s life. And goes up from there. Mix in the possible need to buy a car, pay insurance, pay for parking, etc. and you have a really significant expense.

Do the math: this is 200hrs a year of wasted time and 1000’s of dollars of expense. Then there’s the sustainability angle.

13. Lunch – it’s way easier and less expensive and usually more nutritious to eat at home. There’s preparation time to bring a lunch or there’s a time hit to go out for lunch every day.

14. Increased taxes – In some instances, remote workers can avoid paying higher state income taxes when domiciled in a state where rates are lower.

One can argue that working at home provides a tangible benefit to the team member in the area of $5000-$15,000.

Does Proximity Breed Creativity? Or Contempt?

The above are the practical and largely easy to understand and measure aspects of allowing team member to work remotely. Then there’s the more nebulous aspects and questions as to whether forcing people to work physically close together actually facilitates creativity and problem solving. But that’s a topic for another post.

Friday, February 28, 2014

Covering the 2014 HIMSS Conference Via Social Media

For the last week I’ve taken on the role of culling and sharing select information related to the 2014 HIMSS Conference in Orlando, FL. Since I didn’t want to flood the followers of my @ShimCode Twitter account, I created and used the @HIMSS14 account.

If you are interested in the HIMSS Conference proceedings and highlights, I suggest you check out the tweet stream of the @HIMSS14 account.

You may also want to check out the blog I created especially for the 2014 HIMSS Conference: Unofficial Guide to HIMSS14 Conference Guides. Over the next couple weeks I’m going to share some content, perspective and, of course, opinion on the HIMSS Conference.

Thanks for reading!


Tuesday, December 3, 2013

2nd Reason Why Health Insurance Exchanges Will Continue Floundering in 2014

Last December I offered 3 reasons why I thought the deployment of Federally-facilitated Marketplace (FFM) would flounder in October 2013.

In my previous post I outlined Reason 1 –Enrollment Transaction Processing Generates Widespread Heartburn. Now I’m going to outline the 2nd reason why I believe health insurance exchanges (HIX) will continue floundering into 2014 and likely beyond.

Billing, Payment and Reconciliation Issues Galore

The current 834-related enrollment issues we’re hearing about will lead to payment-related issues; which in turn will lead to coverage and claims payment issues. Stories about incorrect subsidy calculations impacting the accuracy of premium amounts surfaced shortly after healthcare.gov went live. These stories arose from the state-based exchanges and we’ve yet to hear from the FFM.

The important thing to keep in mind is that very few – if any – exchanges have actually deployed functionality for submitting HIPAA 820 (Premium Payment/Order Remittance Advice) to their QHP partners. Of course the fact that these accounting and payment functions have not yet been developed only increases the likelihood of major heartburn arising in Q1 of 2014.

Topics You Won’t Hear About from Main Stream Media

But some things aren’t very sensational nor easy to understand so you won’t hear about them from the main stream media. Here are some accounting and payment related issues you likely won't hear about:

Multiple Sources of Payment

Since all those receiving a subsidy will necessitate a split-billed premium where more than one party is responsible for payment of the premium, the likelihood of premium payment issues leading to eligibility issues is certain to increase. What are the policy and technical requirements for processing members receiving subsidies who do not pay their portion.? Under what conditions can the member re-enroll? Must they pay all their costs that are in arrears?

People Grow Older - Subscribers are not Dependents

There is a dearth of guidance from CMS on handling common life events like aging off dependents, aging into Medicare, how retroactive terminations will be communicated, etc via the 834 transaction.

For families, these processing scenarios are made worse as each scenario needs to clearly differentiate between the subscriber and dependents. Anyone who’s familiar with the 834 transactions knows how finicky the “2300 Loop” can be! :)

The Most Wonderful Time of the Year?

All of the above are being worked on in the most hectic, cut-up month of the year: December. Years from now, I don’t suspect this will be one Christmas that will be memorialized among the “tales of glories of Christmases long, long ago.”

For more information on health insurance exchanges and other health IT topics, be sure to follow me on Twitter.

Friday, November 22, 2013

3 Reasons Health Insurance Exchanges Will Continue Floundering in 2014 (Part 1/3)

Last December I offered 3 reasons why I thought the deployment of health insurance exchanges (HIX) would flounder in October 2013. Now I’m going to share 3 more reasons why I believe health insurance exchanges will continue floundering into 2014 and likely beyond. Here’s reason #1:

Reason 1 –Enrollment Transaction Processing Generates Widespread Heartburn

By law, health insurance exchanges are the system of record for all enrollment transactions originated by a consumer to a qualified health plan (QHP.) The 834 Benefit Enrollment and Maintenance transaction is used by HIX’s to submit new enrollments, changes to enrollment and disenrollments to QHP’s. Unfortunately, there are not any clear operating rules defining how the 834 is to be used for the myriad of new enrollment, change enrollment and enrollment termination transactions that result from the life events a consumer will experience. Moreover, the 834 transaction was never widely adopted across the healthcare industry. Most QHP’s and 3rd parties use their own variation of the 834 transaction to process key enrollment events into their backend systems.

So far, 834’s have trickled out of the exchange and once the flood starts (assuming it ever does), the variability in how QHP’s have implemented their 834 handling will surface.

Note: Operating Rules for enrollment will not even be finalized until July of 2104 and not effective until January 2016.

Then Life Events Occur

After initial enrollment, all subsequent enrollment changes must be originated through the exchange, not the QHP. So when someone loses their job, gets a job, has a child, or has some other life event they need to go back to the HIX and make their required changes. And the 834 exchange process between the HIX and QHP starts over again.

Currently the business rules and edits associated with effecting these changes are largely performed by the QHP. Any incomplete or incorrect data must be caught by the QHP. Then the QHP has to work with the consumer and HIX to correct the issues. It’s not clear there are sufficient automated edits and controls in place to handle the wide range – but common – enrollment scenarios. 

So m belief is that these enrollment issues will create undue heartburn and lead to other issues as 2104 unfolds. I will describe these other issues in subsequent posts.

For more information on health insurance exchanges and other health IT topics, be sure to follow me on Twitter.