The U.S Healthcare Industry is going through an unprecedented 100 year phenomenon - COVID19. It has impacted clients, customers and their families. This White Paper points to Insurance in a Box BPaaS Solutions as a viable business option for Payers to combat COVID19 related healthcare and operational challenges.

1.
Payer in a Box BPaaS
How U.S Health Plans can win during and after the COVID19 epidemic.
Paul Simon Arakkal
Healthcare BPaaS Leader
paul@paulsarakkal.com
Overview
The U.S Healthcare Industry is going through an unprecedented 100 year phenomenon -
COVID19. It has impacted clients, customers and their families. This White Paper points to
Insurance in a Box BPaaS Solutions as a viable business option for Payers to combat
COVID19 related healthcare and operational challenges.

2. 1
Objective of White Paper
This White Paper focuses on Payer in a Box BPaaS Solutions that are available for Payers to
survive and thrive during and after COVID19. This is about making COVID19 a tail wind.
Business Highlights of Leading Health Plans combating COVID19
We reviewed the latest quarterly 2020 results of three leading U.S Health Plans. Please find
below a summary of the actions that they are taking across various categories of market
growth, care and operational services to serve customers during COVID19:
Highlights Cigna Anthem Humana
Market Growth
Expected MA or
Medicaid Managed
Care Market Growth
Cigna will compete
for ~15 million MA
purchasers in 2030
20 % Growth in
Membership in MA
Business
Total MA Retail
Business
membership steady
Medicare Advantage
Business Customers
MA Customers Base
Increased 73 K
MA Members grew
by 200 K/ + 17%
MA Customers grew
by 405 K/ + 12%
Medicaid Managed
Care Customers
No information
shared for Quarter
~ 600 K New
Medicaid Members
156 K New Medicaid
Members (+ 34%)
Cost Waivers
Waiver of Out of
Pockets Costs for
tests and treatment
Through May 31,
2020, for COVID-19
Through December
31, 2020​. ​For mental
health as well.
Waiver with no end
date, Waived
Telehealth cost share
Care innovations
Prescription Drugs Free shipping of
90-day supplies for
prescription drugs
Relaxed prescription
refill policies for
medications
Allowing early
prescription refills
for extended supply
Access to
Pharmacists
24/7 access to
pharmacists
Outreach to MA &
MMC0 consumers to
ensure medications
are on hand.
Script volumes
increased YoY by
9.1% for medication
replenishment
Telehealth Services Moved hundreds of 100s of CA Digital Expanding access to

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Cigna Clinicians to
Telehealth services
for customers
Telehealth Kiosks;
Expanded recruiting
& Onboarding of
Telehealth providers.
Telehealth services,
to reduce risk of
infection & spread.
At home Medication
& Care
Maintained in-home
medication infusion
by Accredo (Specialty
Pharmacy) nurses
Outreach to MA &
MMC0 consumers to
check nutritional &
health needs are met
No information
shared in Quarter
Report
Access to Behavioral
Health
24/7 toll-free help line
to the public to speak
with Behavioral
Health Clinicians
Increased access to
Virtual care and
waived cost-sharing
uptil Sep 30, 2020
No information
shared in Quarter
Report
Digital Health
Solutions / Artificial
Intelligence Solutions
/ Resources to
support the whole
health needs of
members
Health Connect 360
relies on pharmacy
claims, medical, lab
and biometric data,
collected from digital
devices to report a
patient's conditions.
App for COVID19
Assessment to
evaluate symptoms &
assess risk/ connect
to Doctor via text or
video. AI BH Chatbot
SME counseling.
No information
shared in Quarter
Report
Waiver of Prior
Authorizations (PA)
Waived prior
authorizations for
patient transfers, ED
visits, and home
health care services.
Temporarily
suspended select PA
for respiratory/DME
services critical to
COVID-19 treatment
Lifted administrative
requirements
including modifying
PA and referral
requirements
Growth of Population
covered by Value
Based Care
Over 85% of MA
customers in
value-based
arrangements
Medicaid Managed
Care 7.3 M
Customers growing
at 300 K/Year.
2.5 M or 66 % of
membership are in
VBC arrangements.
MA 900 K (8% YoY)
Investments
M & A Priorities 1 Capabilities to better
serve Medicare
Advantage customers
Virtual & Behavioral
Therapy provider
AbleTo for $470
million
Enclara, leading
hospice pharmacy
and benefit
management co,
M & A Priorities 2 Care coordination
and facilitation
Beacon Health
Options, Inc., largest
independently held
behavioral health
organization in U.S
Partnership with
Welsh, Carson,
Anderson & Stowe, to
accelerate expansion
of primary care.
M & A Priorities 3 Analytics and digital AmeriBen, TPA No Info provided

4. 3
Solution Implications for Health Plans
Operations
Claims Processing &
Payments
No information
shared in Quarter
Report
Claims Payable Days
- 46.0 days as of
June 30, + 4.1 days
from March 31, 2020.
A​ccelerate claims
resolution, payments
for Medicaid plans
Simplifying and
expediting claims
processing to speed
up payments and
help ease financial
concerns beginning
in April 2020
Flexible Capacity Need to shift from
COVID to elective
Need to shift from
COVID to elective
Need to shift from
COVID to elective
Employees Work
from home
Majority in WFH ;
Extra COVID Benefits
Majority in WFH ;
Extra COVID Benefits
Majority in WFH ;
Extra COVID Benefits
Enrollment Innovation:
1. How can Medicare Advantage, ACA, Medicaid Managed Care Plans enroll eligible
persons who have lost employer-based coverage after they have missed other
enrollment periods with minimum effort and customer abrasion?
2. How can Medicare Advantage plans enroll members in alternative products or
additional products such as Part D prescription drug plans in quick time?
3. How can Payers enable the success of their producers during upcoming open
enrollment periods, when face - to - face meetings may not be practical with 22 M
existing senior members and 1 M new senior customers who want to enroll?
Care Innovations
4. How can Payers launch and manage targeted communications to direct
vulnerable populations to types of testing, care, and health resources, including
customers in vulnerable groups or in communities hard hit by COVID-19?
5. How can Population Health programs help Payers work with members to organize
well-balanced meals, motivate members to exercise regularly, and keep to good
practices such as adequate sleep, and alcohol/substance abuse via telehealth?

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6. How can Population Health programs help prevent members from seeking
emergency and inpatient care in Hospitals inundated with COVID19 , by
proactively providing in-home care during the COVID19 crisis?
7. How can Population Health help continue to provide non-emergency services
when non COVID patients opt to delay their Doctor’s office visits, via Telehealth?
8. How can Population Health programs adapt to deliver integrated care for
members across a range of providers (like doctors, nurse practitioners, clinical
psychologists, licensed clinical social workers, physical therapists, occupational
therapists, and speech language pathologists) during the pandemic?
9. How can Population Health programs effectively assist in the provision of
behavioral health and social care direct to home based customers and families?
10. How can Utilization Management programs help remove/minimize prior
authorization requirements, and quickly assist in lifting limits on prescription
refills, and help expedite the home delivery of prescription drugs on time?
Investments Planned:
11. How can Health Plans focus their Capital Expenses (CAPEX) on acquiring key care
management capabilities to meet the needs of their customers while accessing
Digital Health capabilities on an Operational Expense (Rental)budget?
12. How can Health Plans access flexible operational applications that are integrated,
simple to operate, and comply with the highest levels of information security even
when their employees or contractors are operating remotely or from office
intermittently, while allowing seamless interactions with ecosystem partners?
Provider Network & Claims Innovation:
13. The COVID19 crisis can increase the possibility of fraud, waste, and abuse. How
can Payers quickly increase the accuracy of claims payment and also institute
payment integrity programs to minimize over and underpayments?
14. How can Payers meet the network requirements, wherein members have
COVID19 related health conditions, or new members acquired, while they migrate
significant % of patients to value based care arrangements with providers, leading
to new enrollment, credentialing and contracting volumes?
15. How can Payers meet regulatory requirements such as TAT when COVID19
outbreaks could cause temporary closures of processing centers, mail rooms, and
contact centers necessitating work from home or remote locations leveraging
roles and rules based access within business process platforms?

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Now that we know what leading Health Plans are doing to combat COVID19, within their
Enrollment, Care Management, Investments Planned and Provider/Claim operations, what
would be the essential features of BPaaS Solutions that Health Plans would need ASAP?
What would Insurance in a Box BPaaS solutions that meet COVID19 needs look like?
Recommended BPaaS Solutions for Health Plans during COVID19
Here are the highlights of Insurance in a Box BPaaS Solutions that Health Plans could rent
from BPaaS Solution providers and respond to COVID19 with precision & speed.
Enroll to Cash Population Health Payment Integrity
BPaaS Solutions that
support Enrollment to Cash
for Medicare Advantage,
ACA and Medicaid Managed
Care plans & products to
meet SEP requirements
Launch & manage targeted
communications to direct
vulnerable populations to
the right types of COVID19
testing, care, & health
resources
Minimize possibility of
fraud, waste, and abuse by
improving accuracy of
claims payment and
establishing payment
integrity program
Ability to enroll members in
alternative Medicare
Advantage products or
additional products such as
Part D products
Work with members via
Telehealth to organize
well-balanced meals,
exercise regularly, and get
adequate sleep, while not
engaging in alcohol abuse
Quickly institute Rules
based, Claims Edit,
Processing and Payment
Solutions to increase auto
adjudication rates
Ability to assist Producers
via mobile & virtual
enablers to win new
customers who may not be
able to meet F2F with them
Prevent members from
seeking emergency/
inpatient care in Hospitals
inundated by proactively
providing in-home care.
Provider Lifecycle
Management
Ability to assist Producers
via mobile & virtual
enablers win existing
customers who may not be
able to meet F2F with them
Continue to provide
non-emergency services via
Telehealth when non
COVID19 patients opt to
delay Doctor’s office visits
Meet the network
requirements in the post
COVID19 scenarios, wherein
new members have been
enrolled post job losses.
Ability to lower costs for
producers for a low yield
season as a result of
financial downturn
associated with COVID19
Deliver integrated care for
members and their families
across a range of providers
including clinical
psychologists, licensed
clinical social workers,
Meet new enrollment,
credentialing and
contracting requirements to
meet the network adequacy
for new customers acquired

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These business requirements can be met through BPaaS solutions that are state of the art
and tried and tested. These solutions can be implemented within a period of three to four
months including value added services such as business process consulting, business
process configuration and provisioning, process migration and ongoing support services.
Business Benefits of Payer in a Box BPaaS Solutions:
Let us now evaluate the Business Value Proposition and Operational Value Proposition of
BPaaS Solutions. These value propositions are applicable to the Payer in a Box BPaaS
Solutions such as Enrollment to Cash, Risk Adjustment, Population Health, Claims to
Appeals and Provider Lifecycle Management.
physical therapists,
occupational therapists, and
speech language
pathologists
Investment Options
Assist in the provision of
behavioral health and social
care, direct to home to
customers and families
Meet the Emergency
Credentialing/Provisional
Credentialing requirements
to meet COVID19 surge
situations in States
Focus OPEX on key care
management capabilities
and Digital Health
capabilities to meet the
needs of their customers
Utilization Management
program to
remove/minimize prior
authorization requirements,
Regulatory Compliance
within COVID19 outbreaks
Access flexible operational
applications that are
integrated, simple to
operate, and comply with
the highest levels of
information security even
when their employees or
contractors are operating
remotely or from office
intermittently, while
allowing seamless
interactions with ecosystem
partners.
Assist in lifting limits on
prescription refills, and help
execute the home delivery
of prescription drugs.
Meet regulatory
requirements including TAT
when COVID19 outbreaks
could cause temporary
closures of processing
centers, mail rooms, and
contact centers
necessitating work from
home/remote leveraging
roles and rules based
access to BPaaS Solutions

8. 7
BPaaS Solution ​Business Value Proposition
I. Optimization of Revenues
BPaaS Solutions allow the optimization of revenue leakage through Enrollment to
Cash, Risk Adjustment, Population Health, Claims 2 Appeals and Provider Lifecycle
Management BPaaS Solutions. These solutions prevent revenue leakage, maximize
risk adjusted revenues, maximize government incentives, prevent overpayments and
underpayments and improve network strength, in that order.
II. Transformed cost structure & Lowest Total Cost of Operations
The BPaaS Solution is delivered from a Shared Services Infrastructure, wherein the
cloud/hosting infrastructure, software applications, and the operations staff are
shared across multiple clients. BPaaS Solution Providers also provide Process
Consulting and Migration Services to move the client operations from the current to
the future operating model. Through Pay per Outcome Pricing Models, Clients avail
the above benefits, making BPaaS Solutions the lowest in Total Cost of Operations.
III. Better Business Outcomes
BPaaS Solutions allow Health Plans to accomplish better business outcomes such
as minimized opportunity leakage in enrollment to cash, improved health outcomes
for customers through population health management and readiness for markets
through provider lifecycle management. BPaaS Solutions optimize payments by
minimizing overpayments and underpayments and by ensuring appeals are
processed accurately and within regulatory timelines.
IV. Benchmark Business Speed and Turnaround Time
BPaaS solutions allow the integrated management of data from intake all the way to
load and complete at the back end. BPaaS solutions also have integrated workflow,
document and data management capabilities. These levers allow the transformation
of operations, improving operational throughput and delivering outcomes within
hours, days and weeks instead of months.
V. Transformation of Stakeholder Satisfaction
BPaaS Solutions transform service outcomes for stakeholders. BPaaS solutions
allow members, producers, and providers to interact with Health Plans directly and
complete work in record time at the highest quality. For example, Population Health
Management allows the integration of health data from Labs, Primary Care
Physicians, Pharmacy, Medical and Behavioral claims to create the personal health

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map of a customer and then enable the creation of an individual care plan which can
then be administered by an integrated provider team to deliver better health
outcomes, delivering higher quality of life and greater member satisfaction.
VI. Assured Patient Safety
Continuous verification, validation and audit of data through the entire process from
start to finish coupled with the highest information security standards such as
HITRUST and HIPAA compliance ensures Patient safety of the highest standard. For
example through roles and rules based process management and automated
verification of credentials with authoritative sources and continuous national
monitoring of providers in and out of the network, Patient Safety can be ensured.
VII. Shortest Time to Solution & Smooth Migration
The BPaaS Solutions are based on configurable, tested software applications and
identified and trained personnel who are familiar with the BPaaS solution. The
implementation of the SaaS/PaaS solution is typically completed within three to four
months, including the provisioning and configuring of software to match the business
process requirements of the client, and integrating with the client’s ecosystem and
with the sources of truth within the Payer enterprise. BPaaS solution providers
typically offer services that map existing processes, design future operations and
execute migration operations to move the client from the current to future operations.
BPaaS Solution ​Operational Value Proposition
VIII. Manage Multiple Products on a Single BPaaS Solution
Typically, BPaaS Solutions have the ability to support multiple Health Plan products.
This capability allows Payers to offer integrated services around these products to
members and customers. This functionality also allows Health Plans to transition
members from one product to the other and also allows the addition of products to a
member’s portfolio. As an example. Providers can be added to the networks of
multiple plans/products leveraging the same Provider Lifecycle BPaaS Solution.
IX. Build a modern, flexible, operations workforce that operates in a pandemic
Payers need people with skills to support new products, new capabilities and
services. Payers are also upskilling their existing workforce and offering more
flexible work environments considering COVID19. BPaaS environments have
intuitive screens, integrated business processes and manage data right from intake
to harmonization with sources of truth. These levers allow employees to become
experts on integrated business process operations focused on outcome as against

10. 9
siloed, legacy applications. Migrating from Provider Data Operations to Provider
Contracting Operations requires transformation of the workforce and BPaaS
Solutions enable the same, BPaaS solutions also allow flexible, remote work.
X. Achieve optimized, flexible Service Operations
Payers often have six roles within their service operations. (a) Intake responsible for
work intake, and data normalization (b) Verification of data leveraging sources (c )
Validation of data leveraging internal data sources and business logic (d) Research
which includes reviewing standard operating procedures, collecting data and
information which is needed to complete the step or sub process or process (e)
Load/Complete which includes loading of data to complete the sub process or
process (f) Audit which reviews the work done from a policy, procedure and data
quality perspective. BPaaS Solutions allow such an operation to be performed by
two roles namely Load/Complete and Audit by rolling the ingestion, normalization,
verification, validation, research functions into the Load/Complete role.
XI. Catalyze increased collaboration within process teams
BPaaS solutions that are based on SaaS/PaaS are typically integrated solutions that
combine functions within the end to end lifecycle such as enrollment to cash, claims
to appeals, population health management, and provider lifecycle management.
These integrated processes allow functional teams that operate within modules of
the BPaaS solution to collaborate across modules. As an example, teams working
within Enrollment could collaborate with those in Billing, Reconciliation, and Appeals
and could even be trained to perform these operations allowing greater flexibility,
XII. Launch Pilot programs quickly
SaaS/PaaS environments allow you to quickly integrate with ecosystem players and
sources, enterprise sources of truths and systems and deliver services including
Pilots because the software applications are highly configurable. You would be able
to expand to adjacent business processes on top of the BPaaS solution quickly,
leveraging Portals, Business Process Management and Master Data Management​.
XIII. Increased Visibility and Control
BPaaS Solutions often allow end to end visibility of the inventory as it passes
through the service operation right from intake, bill, through to reconciliation as an
example. BPaaS Solutions also allows escalation to client personnel for resolution
and approvals leveraging workflow, secure email and notifications via mobile for
speed and convenience. Since BPaaS Solutions have a click by click audit trail
across roles, which can be audited at any time, and checked for compliance, Client

11. 10
Stakeholders retain control over the operations and can view progress and outcomes
versus SLA committed to, by the BPaaS Solution provider.
XIV. Anytime, Anytime, Remote Access, Maintenance and DRP/BCP
SaaS/PaaS software is hosted on an internet cloud infrastructure which can be
easily accessed using APIs and the internet. Access can be through any type of
device including mobile. Upgrades are accomplished through automated options.
Ongoing support is the responsibility of the BPaaS Service Provider. Clients would
need to plan for Business Continuity (BCP) and Disaster Recovery (DRP) mostly
around ensuring employees have the ability on the SaaS and PaaS Platforms, while
the BPaaS Service Provider ensures the availability of SaaS/PaaS solutions through
Business Continuity and Disaster Recovery Planning.
XV. Benchmark Information Security
SaaS/PaaS are highly secure solutions that have several layers of information
security built in. Most of the SaaS solutions are HIPAA compliant while a few of them
are also HITRUST certified. HITRUST integrates requirements across the ISO,
HIPAA, PCI, and NIST, and customizes them to the healthcare industry,
organizational, and regulatory risk factors. HITRUST certification proves that BPaaS
Solution providers have gone the extra mile to strengthen the protection of ePHI in
their environment on behalf of their HIPAA-covered-entity clients.
XVI. Easier Provisioning and Scalability
SaaS/PaaS software is easily provisioned for new clients, customers and users,
When it comes to scalability, the SaaS/PaaS model is highly scalable to 1000s of
users. Since SaaS/PaaS follows the subscription model, Health Plans can choose to
ramp users up or down based on estimated workload, or estimated membership.
XVII. Environment for DevOps
BPaaS service providers typically offer application development services, including
middleware and hardware which means that clients need not spend CAPEX in
acquiring these services. PaaS allows remote development teams to collaborate with
core teams and also work on software applications from anywhere in the world.
PaaS is the perfect option for app development teams who are focused on
developing cloud-based apps. It is mostly accepted and appreciated ​by DevOps
teams​. The coding clock cycles are also low for PaaS. Since web services and
databases are integrated into the environment, scaling DevOps is easier.

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XVIII. Environment for Development, Testing, Running & Customizing Applications
PaaS software is a cloud based platform that includes a runtime environment for
developing, testing, running and customizing software applications. On account of
these capabilities, BPaaS solution providers can easily build and deploy extension
SaaS/PaaS applications. PaaS service providers take responsibility for information
security issues, data backup, upgrades and updates and infrastructure management
simplifying technology operations for clients.
Conclusion
Payer in a Box BPaaS Solutions are a great alternative for Health Plans to combat the
COVID19 pandemic. Here are the four components of Payer in a Box BPaaS.
Payer in a Box BPaaS Solutions​ offer the following business advantages to Health Plans:
Enrollment to
Cash
Management
Population
Health
Management
Claims to
Appeals
Management
Provider
Lifecycle
Management
Optimization of
Revenues
Transformed Cost
Structure
Lowest Total Cost of
Operations
Better Business
Outcomes
Benchmark Business
Speed & Turnaround
Time
Transformation of
Stakeholder
Satisfaction
Assured Patient Safety Shortest Time to
Solution
Smooth Migration to
Future State