When Holidays & Healthcare Open Enrollment Collide

Lack of transparency in health plans is enough to give most people heartburn.

Holiday gatherings in my home are very traditional. Take our last Thanksgiving, which found us embracing such time-honored pastimes as watching the Macy's Parade while the turkey roasted, cheering for our favorite sports teams throughout the day, and pausing between bites and courses of dinner to talk about health insurance.

Yes, health insurance topics are right up there with the Snoopy balloon for my family on Thanksgiving. Maybe this is true at more tables nationwide, given how the Affordable Care Act and retail health have brought new importance and challenges to open enrollment season. But my family might be a bit different, considering most of us work in healthcare.

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In our house, after the Thanksgiving dinner plates are cleared, we play a version of "stump the chump" using health benefits as the topic. As of November, those enrolled in January-effective policies (more than half of us) had been using benefits for 10 months of the year. Some may have seen their primary practitioner once or twice, while others, facing more significant health events, have required more frequent interactions. Everyone started the year with a more or less even playing field of cost sharing -- deductibles, co-pays, and out of pocket maximum payments (OPX).

Over pecan pie, we try to figure out the best course of action to take on health questions for the remainder of the year. By Thanksgiving, most have begun thinking about health needs for the coming year while reviewing health services for the past year -- looking at current health plan balances and trying to determine what's going on with our explanations of benefits (EOBs). Inevitably, there is data missing in the EOBs to describe the context of the claims processing and financial accounting.

Read the full article on InformationWeek.

Susan Taylor brings to Pega her 20 years of successful experience with payer and provider technology and operations, most recently from Oracle Corporation. Prior positions include Sr. Director of IT and Operations, responsible for Harvard Pilgrim's enterprise business ... View Full Bio