The long-term value of automating Summary of Benefits and Coverage (SBC) communications

Sohail Malik, Business Product Manager, Healthcare Vertical, Elixir Technologies
Sohail Malik, Business Product Manager, Healthcare Vertical, Elixir Technologies

On December 22, 2014, the Departments of Health and Human Services, Labor and the Treasury issued regulations proposing changes to the Summary of Benefits and Coverage (SBC) requirements and CMS templates to make them more user-friendly. The proposed changes wouldtake effect on or after Sept. 1, 2015.

The process to create the initial SBC in 2012 was a technical challenge for many health plan providers. With a fully automated document process not yet in place, many organizations met the 2012 requirements with a workaround approach that often meant building SBCs manually through Excel spreadsheets or engaging third-party providers to create the SBCs using similar time-consuming and often expensive methods.

Two challenges needed to be addressed – identifying source data and mapping the calculations to the SBC template fields. The sources needed for SBC calculations are typically contained in a variety of systems across an organization. As a result, it is often difficult to identify the location or owner of the particular data required.

Once the data is identified, there are business rules and calculations that must be applied before mapping it to the appropriate fields in the SBC template. Without a proper staging process, managing SBC data is certainly a difficult task in the short term – but has the potential to become nearly unmanageable in the long term. The SBC template is a standard information structure and the physical data layout is specific, including the number of pages and the type of information required on each one. When presenting SBC information, these formatting characteristics apply whether the plan is a simple one or has large amounts of data to be summarized. Many plans use word processing software but, because the application cannot dynamically format pages, they must manually design and organize the content for each SBC.

While workaround manual processes have met the compliance requirements of the market from 2012 to the present, they are nevertheless prone to significant inefficiencies and potential inaccuracies. In the absence of an automated approach to content management, healthcare payers seeking to comply with the SBC modifications will continue to face production hurdles. For example, a payer with tens of thousands of SBCs may need to engage hundreds of persons to assemble Excel worksheets, perform the necessary calculations and format the documents. Smaller payers with fewer SBCs will face a proportional burden. Additionally, those still using manual processes will experience a recurring struggle each month with the contractual requirement to provide new SBCs for renewals in a timely manner.

In light of these challenges, the new SBC requirements on the horizon may be just the nudge needed to seek a more effective way to handle these (and future) SBC modifications. Automating the workflow for preparing SBCs provides a clear long-term solution for the foregoing hurdles. A flexible data model and a centralized data mapping system are required to effectively prepare and manage SBC data as plans or CMS requirements change over time.

Five considerations when adopting an automated SBC approach

Once a company makes the decision to improve internal SBC document processes, a thorough evaluation of what needs to be part of the solution is necessary. Here are five considerations to keep in mind during a review:

  • Typically, critical data for SBCs and related materials reside in disparate parts of the organization. An effective automated, template-based content management approach requires technology that can identify source data, access this data easily, aggregate it and normalize it in a common data schema.
  • Ensuring the ability to set up a data-driven master SBC template that can be easily changed is essential to avoid cumbersome and expensive manual processes.
  • It is important to have the capabilities for batch and on demand generation of SBCs to meet organizational requirements over the long term.
  • Look for a content management system that allows even non-technical line of business users to manage SBC changes due to new government, legal or other required language modifications. Having this capability will avoid the time-consuming and costly process of calling upon the IT department or third-party provider to make changes, which may be as simple as adding a period or comma or changing the wording of a sentence.
  • The master template should have a rich composition tool with the ability to accurately complete complex calculations and generate all required SBC tables.

Achieving efficient compliance and more

If your document processes include the foregoing features, your business will not only have the capability to reduce the compliance burden and risk of non-compliance penalties, but will also be able to significantly enhance time-to-market and provide the critical agility sales teams need to negotiate effectively on behalf of the organization. Having the ability to make immediate and easy-to-implement changes to SBCs makes it possible to generate SBCs on demand for showing real time comparisons. For example, a sales representative in the field may want to change the co-pay or some other attribute of the company’s product and produce the SBC on the spot, placing it side-by-side with a competition’s offerings. Having this capability will support sales efforts with the ability to deliver complete and easy “I need it now” information customers expect.

Automating the production of SBCs delivers a return on investment that rests in the ability to proactively address the demands of today’s crowded, ever-evolving, information-based healthcare market on more than one front. The ideal strategy for any healthcare payer is to implement easy-to-use automated document processes that enable compliance now, but have the features and scalability to meet an organization’s broader strategic goals over time.

Department of Health and Human Services, Department of Labor, Department of Treasury, Elixir Technologies, SBC, Summary of Benefits and Coverage


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