Government Mandates - BCBSA and CMS (Highmark)

I will take the medicare advantage project as an example to explain my role in all government mandate projects that I have taken care of. These projects took any time between 3 months (accelerated) or 1 year (phase-wise implementation of large projects).

My Role
Business Requirements Lead
1.5 Years
Skills Used and Nurtured
Requirements elicitation, Project management, Communication through documentation,
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The Challenge

  • The project was critical due to its direct impact on star ratings which are the most important metric that health plans track. The rating system gives the customer a way to consider quality as well as cost as they make their enrollment decisions. Medicare evaluates plans every year and scores them on a scale of 1 to 5 stars, with 5 stars indicating the highest performance. Due to this, the project had high visibility for appreciation as well as escalation.
  • The multiple types of communication at different time stamps with hundreds of home-host combinations in all time zones of the country made the project challenging.
  • Ensuring that the participating plans provide the information which is required for the other party to work on without the intervention of the association, was a challenging task.
  • One delay in communication or one mismatch of information can completely screw up the whole communication thread and everything had to start again leading to delays and in turn reduction in star ratings for the health plans.
  • Another challenge was to keep 5 clients on board customizing the solutions as per everyone's needs and delivering in the limited time frame to be compliant with the mandate.
  • The final layer of complexity was added by the fact that the same home plan can also act as a host plan for some other plan. This induced communication confusions in the times when face-to-face meetings are impossible due to stakeholders spread over the geography.

The Process

The exact process of the project is confidential and could not be disclosed, however, I will try to layout the process where I was involved.

After the association announces an implementation deadline over a group call of over 200 attendees from all blue plans, the health plans develop its strategy as to how they want to take it - manual or automation.

After a few internal decisions and approvals on the executive level (exact process obscured), my role begins. I start with understanding the mandate and how it will affect the actual end-user of the change. I digest the association documents and translate them into the simple business language to consult with different health plans who are using out enterprise health care platform. I gauge their understanding of the solution and suggest possible ways to implement the mandate and be compliant with the government mandate with the deadline. Sometimes a manual approach makes more sense considering the volume of work the change will affect.

Understanding their requirements and consulting the changes with an internal technical team, I prepare a business requirements document which also contains the estimated cost that the implementation will incur with a detailed breakdown of work efforts. This involves understanding the business language and putting it in precise words in a document while empathizing with the customer to learn their actual usage and pain point. I continuously suggest better and efficient ways to implement the mandate so that the change remains open to further enhancements considering the fact that US healthcare is a patchwork of continuous changes and updates. Upon approval of the business requirement document that I prepare, it is then passed over to the technical team to help them build the technical requirements after which technical team starts their development. Parallelly, I track the progress, risk and dependencies and keep communicating that to all business stakeholders. Th project managers and solutioning leads perform their roles but I have not vetted it here to maintain confidentiality about the whole process.

To conclude, my role starts with understanding the implementation from the customer's perspective, asking the right questions, documenting the implementation, tracking the development and ends with assisting the technical teams as well as business teams with the understanding of the solution and the mandate.

The Impact

  • The direct impact of this project is on the star rating of the organization that I am consulting for.
  • These projects help the clients save millions of dollars which they would have otherwise lost in reduced customers and government bonuses.
  • The interim manual approach process design not only helped the client in smoothly vetting out the process for the users on the business side but also prepared them for automated process understanding and handling it without errors and mistakes.