Dealing with Duals- Membership and Benefit Administration

Dealing with Duals- Membership and Benefit Administration
Mary-Ann Calderon, Advisory Consultant – March 2, 2015

Health plans considering implementing an integrated enrollment and claims processing solution for Dual benefit plans should consider the following:

- Where are the opportunities for operational savings?

- What does the plan’s Operational Readiness look like?

- Is there dedicated leadership and organizational commitment to implement an effective solution?

- Are adequate resources available?

- What is the level of effort and timeline to implement a streamlined solution?

- Is there a solution to be implemented which will be both scalable and flexible to support future growth for both memberships and models of care?

- How will the benefits of implementing a Dual solution be measured?

Depending on the claims processing application the client is using in conjunction with the Federal and State requirements, there are typically two paths available for the client to choose from when determining the appropriate solution:

- Out of the box software solution available for purchase from the vendor

- Custom developed solution

When making recommendations I always take in to consideration timelines for implementation, budget, support and maintenance, and functional requirements to determine which option provides the best return on investment. In some circumstances, a hybrid of both paths described above may be leveraged resulting in a custom solution first being developed and implemented to enable the health plan the ability to meet government regulations while a long term (and possibly more costly) vendor software solution is implemented. This is typically done when a health has a tight timeline for initial implementation, the introduction of the new (DUAL) line of business will help drive overall company growth, and the organization does not want the long term responsibility for additional maintenance and development of the custom solution that was initially implemented.