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#6: Avoiding Enrollment “Meltdowns”

Enrollment, and all the procedures and production around it, is one of the building blocks of successful implementations, client and participant satisfaction and of course, accuracy in adjudication. It seems it would be an easy process, but I can’t think of a TPA that hasn’t experienced a “meltdown” caused by a breakdown in enrollment.

How do I define “meltdown”? It really depends on a TPA’s tolerance level. How about calls from angry participants that they cannot obtain their scripts from a pharmacy? How about the stop loss claim filing where review of the enrollment record shows that the participant was added before the waiting period or should have been terminated before the large claims were incurred? How about EDI claims unable to be loaded to the claims system because there is no enrollment record for the patients? A simple definition could be any situation which leads to disruption in normal workflows or erosion of client trust and satisfaction.

The reality of enrollment is that it is touched by many, with less than stellar focus and commitment to quality. Just think about it. A perfect enrollment first requires the covered participant to completely and accurately supply information. Then, representatives from the Plan Sponsor would need to verify the data and supply coverage information. That gets even murkier when they utilize a third-party like a payroll or benefit administration company for management of the enrollment. The larger payroll companies work on their own terms with as little focus on benefit enrollment as possible. The others work very hard, but often compete on cost and can’t invest heavily in the resources and controls which are necessary. The benefit enrollment firms are a completely different story. Most see welfare benefits (i.e., group health) enrollment services as a “throwaway”, with heavy focus on voluntary benefits.

On top of the issues with the origins of data received are potential complexities with the various methods of receipt, including manual “emergency” loads, requests through Customer Service to update demographics, electronic files and entry via a web portal. Synchronization is a major challenge. Finally, additional complicating factors are variances in the eligibility provisions by Plan and the need to provide business partners (PPOs, PBMs, etc.) with timely and regular files.

Best Practice Enrollment Management and Controls

In my many years of working with TPAs I have seen many strategies for managing enrollment utilized, and made sure to document what I considered to be “best practice”. These strategies fall into four categories: staffing and organizational structure; application of technology; operational controls and audit. Let’s look at “best practice” in each of the areas:

Staffing and Organizational Structure

  1. Do not erode the focus of staff involved with management of enrollment data by adding multiple “administration” responsibilities like COBRA administration, billing, funding and FSA/HRA administration. Do you function optimally when you are trying to finish something in the office and must also plan travel and submit an expense report?

  2. Staff adequately. Although the metric will vary based on the number of groups involved, the number of coverages and plans and turnover within the groups, a staffing ratio of one dedicated representative for each 7,500 covered employees is a good benchmark.

  3. Do not look at an enrollment representative as an entry-level position. The most important part of the job is thorough examination of the transaction against Plan rules and identification of research/resolution necessary. Hiring should focus on analytical abilities and attention to detail.

  4. Maintain a close working relationship between the enrollment team and Account Management. Proactively addressing issues with enrollment transactions received before they morph into “meltdowns” is essential.

Application of Technology

  1. Clear separation of responsibility must be maintained in the TPA’s system so that only appropriate individuals can change enrollment data. This includes adding new enrollments, processing terminations or changing coverage. In many cases, you will hear me talk about “reducing hand-offs”, but when it comes to enrollment knowing the why and when is as important as the transaction itself. The routed transaction from Customer Service or the e-mail from a client or Account Manager is invaluable to the audit trail.

  2. This seems obvious, but make available every possible alternative to manual handling of enrollment transactions. This includes a web portal and the ability to accept electronic files.

  3. Speaking of the various options, make sure there is clear parameters around how and when data is received so that updates do not overwrite critical changes in the system. I can’t tell you how many times in auditing for large employers I found that the TPA handled an emergency load or change for a client, only to have a subsequent file load erase or reverse the changes.

  4. For web portals, understand and manage to whether the portal facilitates “forms-based” data entry or “logical” data entry. It makes a world of difference on the overall quality of data received. In its simplest form, a “logical” system mandates that all required fields must be completed during the enrollment. There is also verification of, or shortcuts to, matching addresses, verification of transaction dates for logical sequence and verification of coverage type with demographics. “Forms-based” web portals require much greater scrutiny during the process of loading the records into the administration system.

  5. For file-based exchanges, make sure to exchange Companion Guides with the trading partner and completely reconcile differences. This takes discipline, but is the foundation for ongoing quality assurance and auditing around data discrepancies.

  6. Beyond the Companion Guide, seek to understand the trading partner’s internal procedures and timing. Do they attempt to “clean-up” data? Do they pass on a post office box in the physical address field if that is the way they received it? If dependent birth dates are missing, do they pursue them or just send empty fields? From a timing perspective, the TPA must understand the timing of transactions between the Plan Sponsor and enrollment vendor and between the vendor and TPA. This is important during an annual enrollment as well as on an ongoing basis.

  7. Develop capabilities for quality assurance on files BEFORE they are loaded. These are systematic reviews which can identify issues with the entire file or with individual transactions. I have a litany of embarrassing examples including Donald Duck and Test Case showing up on a client’s list bill to more than 50% of a group being terminated due to a programming error. Minimum standards on a “macro” basis in this area should be identification of the total number of records, number of new enrollments and number of terminations, with comparison to historical counts. Obviously, aberrations would be addressed with the enrollment vendor or client. On a “micro” basis, any changes to unusual data fields must be identified and researched by the Enrollment Representatives. Examples are changes in SSN or other identification number, changes in birth date or a mid-year change in the plan of coverage (i.e., where a qualifying event must be verified).

Operational Controls

  1. First and foremost is gaining a complete understanding of the enrollment provisions of each Plan administered, with key elements highlighted for quick reference and unclear provisions clarified with the Plan Sponsor. Whereas there may be claims in the “grey area” requiring some discretionary authority by the Plan Sponsor, there should be none from an enrollment perspective.

  2. There must be clear standards established for documentation of the system or client files during research or reconciliation of unusual transactions. The last set of “best practices” involve audit, and controls should allow for no transaction without a complete audit trail including the date, user handling the transaction, the transaction itself, and background information supporting the decision or transaction.

  3. One of the areas most discussed with my clients is whether information gathering relevant to other TPA operations should be reactive or proactive. An example of “reactive” is gathering the cell phone number and e-mail address of a covered participant when they call Customer Service. Another is requesting information about other coverage after some time has passed or something on a claim indicates other coverage. “Proactive” involves outreach to the covered participant at regular intervals to obtain the same information. I would offer that proactive data gathering has significant operational benefits IF done logically and as unobtrusively as possible.

  4. The final operational control could be considered an “audit” function in nature but involves regular (i.e., at least once or twice per year) reconciliation with the client or enrollment vendor. This must include client review of an enrollment report with all participants (employees and dependents), effective and termination dates and coverage in place. This can be handled systematically with an enrollment vendor, comparing the most recent file with the current enrollment record.


  1. When you think about the downstream issues with an inaccurate enrollment record (e.g., unhappy members due to ID card misspellings, claims paid under the wrong plan, participants denied scripts in the pharmacy, etc.), audit of enrollment records may have the greatest return on investment of all things a QA Department can do. Best practice suggests that 25% or more of manual entries should be audited, including web transactions and anything identified through system edits.

  2. In addition to audit, it is incredibly important to track, report and trend issues identified through Customer Service or other Departments. I have seen major issues with client staff, internal staff and enrollment vendors identified this way. Items to be tracked should be ID card corrections, returned mail, returned e-mail, participant calls about incorrect data, claims not matching enrollment records and PBM service issues.

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