Blog Posts Health IT Process Management

A Healthcare Holiday Carol

A Healthcare Holiday Carol

T’ was the end of AEP, when all through the health plans
Operations were stirring with implementation mayhem.
The actuaries’ calculators were put away with care
In hopes that record enrollment soon would be theirs.

Product development teams were all snug in their beds,
While enrollment applications danced in the processors’ heads.
Portals, exchanges and broker applications hummed,
Testing analysts confirmed the right configuration had been done.

Out in the call center arose such a clatter
CSR managers asked “What was the matter?”
Provider networks, deductibles, service requirements too
So many answers to questions that few of them knew.

New enrollee packages fill the out-going mail
ID cards are printed without a minute to spare.
When, what to my wondering eyes should appear?
Incoming piles of member grievances and appeals.

Auditors review data, so lively and quick,
CMS gives the universe requirements to pick.
More rapid than eagles comes regulatory change.
ACA and transmittals, can’t any two be the same?

Now the DOI also has objections for review.
SOBs and EOPs are finally approved.
To manage escalations, we have to look at them all.
How many inquires where resolved in one call?

EDI transactions continue to fly.
834s and 820s, mount to the sky.
When 270s are received, send the 271.
Here comes the 837, with the 835 are we done?

Auto-adjudication is still not the ultimate fix.
Send a 277 in response to the 276.
14 days is the average claim turn around.
Allowing plenty of time for provider checks sent electronically, air or ground.

So much to handle, almost beyond reason.
All happening within the short holiday season.
Here at Pega we believe you are all dynamite!
Wishing “Happy AEP to all, and to all a good-night!”


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