Payers and Managed Care Use ENS® to Streamline Care & Member Services

There are several ways in which the health plan, payer, ACO, and Managed Care Organization (MCO) can use ENS towards improved and more cost efficient care coordination. This includes identifying opportunities to open lines of communications between hospitals, ERs, and payers; streamline transitions of care to the benefit of provider and patient; and raise awareness about potential instances of fraud for a member’s multiple or out of state hospitalizations. For example, ENS notifications contain the patient contact information gathered by hospital registration staff, which is historically more accurate than what is provided to a health plan. MCOs or health plans can look for patient addresses in ENS notifications that are outside of the state in which they provide coverage. For some members, the plan has a contractual requirement with CMS to attempt to validate member addresses that may be outside their service area. On a quarterly basis, a list can be compiled of all ENS notifications pertaining to members who provided out-of-state addresses at the hospital. From there, the list can be culled to remove members in the age range of a typical college student (or younger), and then remaining members can be contacted to validate addresses.

The health plan or MCO can also use ENS to steer members from using out-of-network hospitals to in-network hospitals. They scan their ENS notifications for the presence of out-of-network hospitals. When they notice one, they may contact the member, explain to them that using out-of-network hospitals cuts into the MCO’s budget to a greater degree or may effect the overall amount of coverage the plan can provide in the future, and then points the member in the direction of the nearest in-network hospital. The MCO reports that this strategy has been very successful.

Workflow Integration

  1. The MCO pays closest attention to ER admit notifications, as they are already notified of inpatient admissions beforehand through hospital prior approval requests.
  2. The MCO has internal tools to track different subsets of their membership: high utilizers, chronic diseases, children, expecting mothers, etc. Each subset has a dedicated case manager. They take their ENS notifications and check them against each subset’s list of members. If the patient in question is on one of the member subsets, then the notification is routed to the appropriate case manager. This helps immensely with triaging which patients require most immediate support.
  3. The MCO also has a general outreach team that does not divide their member population by subsets and reaches out to each member who is the subject of a notification. Since they don’t have subsets to check against, the amounts of prior encounters in the notification summaries is very valuable to them.