The healthcare industry is going through a dramatic transformation driven by several powerful factors, including technological advances, a rapid shift toward consumerization, and evolving reimbursement models—particularly the move toward value-based care.
"Imagine you’ve recently visited your primary care physician and she has referred you for a procedure by a specialist.
You have heard about surprise bills and want to contact your health plan to confirm insurance coverage of the procedure. Your health plan is separate from your provider’s health system and although the office staff of the specialist said they believe you’d only have a co-payment, you want to double check so that you’re not hit with any unexpected medical costs later down the road. You start by calling your health plan where you navigate through the IVR phone tree only to be placed on hold.
After waiting over 20 minutes, a representative finally answers your call, verifies your name and date of birth, and asks for the reason for your call. After explaining that you need information on coverage for your upcoming procedure, the representative is not familiar with the procedure that you need or the doctor performing it, and places you on hold again to gather more context. You end up waiting another 15 minutes without anyone getting back to you.
You have another call to make and cannot spend an additional minute on hold, so you try logging on your health plan’s mobile app to find information on your coverage. You navigate the app and select the tab where you expect to see a summary of your health plan coverage. This gives you a list of your past appointments with the associated Explanations of Benefits.
You try a different section and only can find general policies about specialist referrals, but nothing about the procedure you need. You try to search the app to find out if a prior authorization is required, but can’t find any specifics about that either. And the “contact us” tab directs you to call the same number you are on hold with."
